Advances in Ablation Therapy for Ventricular Tachycardia Nitish Badhwar, MD, FACC, FHRS Director, Cardiac Electrophysiology Training Program University of California, San Francisco For those of you who watch what you eat, here's the final word on nutrition and health. It's a relief to know the truth after all those conflicting nutritional studies. 1. The Japanese eat very little fat And suffer fewer heart attacks than Americans. 2. The Mexicans eat a lot of fat and suffer fewer heart attacks than Americans. 3. The Chinese drink very little red wine and suffer fewer heart attacks than Americans. 4. The Italians drink a lot of red wine and suffer fewer heart attacks than Americans. 5. The Germans drink a lot of beers and eat lots of sausages and fats and suffer fewer heart attacks than Americans. 1
CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you. Non-sustained ventricular tachycardia (NSVT) 3 or more consecutive QRS complexes of ventricular origin at rate of more than 100 bpm Sustained VT Lasts more than 30 seconds, usually requires intervention for termination Monomorphic VT Uniform QRS configuration Polymorphic VT Beat to beat variation in QRS configuration Electrical storm > 3 VT/VF episodes in 24 hours Definitions Clinical Manifestations Sudden cardiac arrest (ventricular fibrillation) Syncope, near syncope Palpitations with wide complex tachycardia (hemodynamically tolerated) or frequent PVCs 2
Wide complex Tachycardia 1. VT 2. Pacemaker mediated tachycardia 3.Artifact 4. WPW with preexcited tachycardia 5. SVT with aberrancy Bigeminal PVC 3
Holter monitor PVC induced Cardiomyopathy Associated with high burden ( >24% Holter burden...bogun et al) Monomorphic PVCs Cardiomyopathy reverses with ablation of PVC Mechanism not well defined?interpolation?dyssnchrony?rate related Idiopathic VT VT associated with structural heart disease 4
Polymorphic VT /VF Monomorphic VT Outflow tract VT- RVOT VT, LVOT VT,cusp VT Fascicular VT- LAF, LPF, Septal Annular VT- Mitral, Tricuspid VT from crux of heart I II III avr avl avf V1 V2 V3 V4 V5 V6 5
Pulmonary valve Ablation site Tricuspid valve Idiopathic LBBB VT may originate above the Pulmonary Valve Outflow Tract VT 6
ESI Anatomy (RAO) Epicardial and CS catheter Epi Epi CS CS 7
Left Aortic Cusp VT Left Aortic Cusp VT Left main coronary artery Ablation catheter Intracardiac ultrasound showing ablator in L coronary cusp 8
Aortic Cusp VT ECG Criteria Early transition in precordial leads (V1, V2) Tall R waves in inferior leads Notch in V5, lack of S in V5, V6 Broad R wave in V1, V2 Larger R/S amplitude in V1, V2 Notch in V1 in L cusp VT (transeptal conduction) Lead I negative in L cusp, positive in R cusp Phase analysis (as measured from earliest surface onset) Local onset in V2 7 ms Initial peak / nadir in III 120 ms Initial peak / nadir in V2 78 ms LVOT VT (Aortomitral continuity) Left Posterior Fascicular VT 9
Features Induction with atrial pacing RBBB, LAD No structural heart disease (Zipes, 1979) Verapamil sensitive (Belhassen, 1981) RBBB, RAD (Ohe, 1988) Upper septal (Shimoike, 2000) Left Anterior Fascicular VT Fascicular VT 10
Mitral Annular VT a. Anterolateral b. Posterior c. Posteroseptal PVCs arising from Posterolateral Tricuspid Annulus PVC from the Crux of the Heart 11
VT arising from Crux of the Heart VT arising from Crux of the Heart LAO RAO 12
Idiopathic VT VT associated with structural heart disease LV Septal VT LV Septal Fibroma 13
Real Time Intracardiac Ultrasound Coronary artery disease Idiopathic dilated cardiomyopathy Hypertrophic cardiomyopathy (HOCM) Arrhythmogenic right ventricular cardiomyopathy (ARVC) Infiltrative cardiomyopathy- amyloidosis, sarcoidosis Chagas disease Congenital heart disease Tetrology of Fallot, aortic stenosis Valvular heart disease Pre surgery Post surgical repair Mitral valve prolapse Right sided AV bundle, fibrotic scars in septum, degenerative changes in conduction system Myotonic dystrophy AV block more common Familial VT Genetic abnormality of conduction system 14
Ischemic VT Ablation in the Left Ventricle 15
Ablation approaches Catheter ablation during VT (critical area of slow conduction) limited by hemodynamic stability Catheter ablation in sinus rhythm (scar mapping) Channels Late potentials Pace mapping Long term results 50-60% Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) 47 16
ARVC: Ventricular Tachycardia arising from Right Ventricle 49 Role of imaging modalities in the diagnosis of ARVC Holter Carto RV angio MRI Non ischemic Dilated Cardiomyopathy Annular scar VT arising from the conduction system (bundle branch reentry, fascicular, interfascicular Epicardial scar 17
Bundle Branch Reentry VT Bundle Branch Reentry Reentry circuit is confined to the left and right bundle branches Usually LBBB, during sinus rhythm Presents with: Syncope Palpitations Sudden cardiac death Treatment: RF ablation of right bundle Catheter Ablation of Right Bundle Branch I V 1 II RA Current Voltage 18
Epicardial VT in Patient with Dilated Cardiomyopathy Failed VT Ablation Redo endocardial mapping with remote navigation Mapping with hemodynamic support (IABP, echmo, LV assist devices (Impella, Tandem heart) Epicardial and endocardial mapping Hybrid procedures (OR) Remote Navigation (Stereotaxis) 19
Impella device and VT Ablation Subxyphoid Access to Pericardial Space Epicardial Mapping 20
Epicardial VT: EKG criteria QRS duration > 200 ms Pseudo delta wave > 34 ms Intrinsicoid deflection > 85 ms Shortest RS > 121 ms Precordial MDI > 0.55 ms Non ischemic cardiomyopathy: lack of q wave in inferior leads, positive q wave in lead I Epicardial VT Chagas 30-40% Non ischemic cardiomyopathy 25-50% Ischemic cardiomyopathy 10-15% ARVC 5-10% LV aneurysm, Sarcoid, Non compaction Idiopathic VT 10% (mainly around epicardial arteries) Conclusion Ventricular tachycardia is an important cause of sudden cardiac arrest ECG characteristics can localize the site and origin of VT Idiopathic VT Monomorphic VT / Frequent PVCs curable with catheter ablation Polymorphic VT treated with ICD and drugs VT associated with structural heart disease ICD and antiarrhythmic drugs Catheter ablation is mainly palliative, improved efficacy with epicardial mapping, impella/echmo/iabp 21
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