Treatment of VT of Purkinje fiber origin: ablation targets and outcome Ch. Piorkowski University Leipzig - Heart Center - Dept. of Electrophysiology Leipzig, Germany
Presenter Disclosure Information Gerhard Hindricks has received honoraria for lectures from Biosense, Stereotaxis, St. Jude Medical, Biotronik Gerhard Hindricks is a member of the Advisory Board / consultant for Biosense, St. Jude Medical, Biotronik, Stereotaxis, Cyberheart
Catheter ablation of Purkinje-triggered VT The successful mapping and ablation of polymorphic ventricular tachycardia and ventricular fibrillation was introduced by Haissaguerre and colleagues (LQT / Brugada patients). Their observations and scientific work opened up a new window for interventional electrophysiology, i.e. Catheter ablation of VF. The patient population studied so far is small, however, over the years several groups have contributed their experience and to extend the potential option for catheter ablation to other patient subsets.
Catheter ablation of Purkinje-triggered VT Catheter ablation has of Purkinje triggered VT / VF has been successfully reported: - idiopathic VT / VF - Brugada Syndrome - LQTs - post MI - after AVR - myocarditis - dilated cardiomyopathy
Catheter ablation of Purkinje-triggered VT Catheter ablation has of Purkinje triggered VT / VF has been successfully reported: - idiopathic VT / VF - Brugada Syndrome - LQTs - post MI - after AVR - myocarditis - dilated cardiomyopathy
Catheter ablation of Purkinje-triggered VT 66-year old male CAD, LVEF 45%, underwent CABG 7 days after CABG recurrent pleomorphic and polymorphic VT and VF coronary angiography, RCA-stent VT/VF remained, > 200 defibrillations
Recurrent VT/VF 10 days after CABG
12-lead-ECG I II III avr avl avf V1 V2 V3 V4 V5 V6
12-lead-ECG I II III avr avl avf V1 V2 V3 V4 V5 V6
12-lead-ECG I II III avr avl avf V1 V2 V3 V4 V5 V6
12-lead-ECG I II III avr avl avf V1 V2 V3 V4 V5 V6
12-lead-ECG I II III avr avl avf V1 V2 V3 V4 V5 V6
Transseptal LV-mapping
LV-mapping: Morphology I I II V1 V5 ABL -10-10 -40-50 -55
LV-mapping: Morphology II I II V1 V5 ABL 0-15 -40-50 -65
LV-mapping: Substrate morphology I and II I II V1 V5 ABL -15-15 -25 30-35 -45
Case I: After successful ablation of VT/VF
Ablation of ventricular tachycardia: Electrical storm/polymorphic VT early after AMI Circulation 2003 JACC 2003
Catheter ablation of Purkinje-triggered VT 16-year old girl 09/05 palpitations and pre-syncope documentation of wide-qrs tachycardia (290 ms) slightly reduced LVEF (55%), RV normal
Catheter ablation of Purkinje-triggered VT normal coronary arteries, LV-biopsy myocarditis (herpes virus, HHV6) recurrent ventricular tachycardia ICD-implantation Re-admission with incessant VT
12-lead-ECG I II III avr avl avf V1 V2 V3 V4 V5 V6
Holter-ECG CL 290 ms
12-lead-ECG I II III avr avl avf V1 V2 V3 V4 V5 V6
Endocardial mapping
Ventricular tachycardia exit site I II V1 V6 HBE RVA
Pace mapping at exit site I II III avr avl avf V1 V2 V3 V4 V5 V6
Endocardial mapping
Endocardial mapping - substrate I II V1 V6 HBE RVA
Bode et al., PACE 2010
Catheter ablation of VT / VF: Leipzig data 14 patients with focal triggered VT/VF 8/14 post MI 2/14 post AVR 3/14 slightly impaired LV-function one myocarditis Ablation targets were septal LV in 12/14, LV and RV in 3/14, septal and free wall in 2/14. Acute termination was achieved in all pts., recurrence of any VT/VF after 26±14 months was 3/14.
Knecht et al.; JACC 2009
Catheter ablation of idiopathic VF 30/38 pts. (81%) had spontaneous VPB 8/38 pts. (19%) had no spont. Acivity VF triggered from the right PS 16 pts., the left PS in 14 pts., and both in 3 pts. a mean of 1.7±2.0 VBS were targeted Knecht et al.; JACC 2009
Catheter ablation of idiopathic VF during FU (6 yrs) 7/38 pts. developed recurrence of VF within a median of 24 months (1-60 mo). 5/7 pts. underwent re-ablation, 4/5 pts. had new VPB morphology, only one had a recurrence of clinical VPB all pts. underwent successful re-ablation without recurrence in the next 28 months. Knecht et al.; JACC 2009
Summary Focal triggered VT/VF can be observed in the absence of organic heart disease as well as in patients with a variety of cardiovascular diseases. Localization of such triggers is possible, the Purkinje system seems to play a predominant role. However, PVB activity is a necessary for mapping and successful ablation. Recurrence of VF/VF is infrequent, however, as a rule, ICD implantation is recommended to prevent SCD as a result of arrhythmia recurrence.