Πρώτης γραμμή θεραπεία η κατάλυση κοιλιακής ταχυκαρδίας στην ισχαιμική μυοκαρδιοπάθεια Δ. Τσιαχρής Διευθυντής Εργαστηρίου Ηλεκτροφυσιολογίας - Βηματοδότησης, Ιατρικό Κέντρο Αθηνών, Αθήνα
Ventricular tachycardia ablation There is a general consensus on when and how to do it
First or second line??? Reentrant VT (last line) Multiple episodes ES (± AADs) Failed AADs Not reentrant VT (first line) PVCs BBRVT Fascicular PVT
Issues. First line at different clinical settings ES incessant VT multiple shocks first shock at ICD implant before ICD implant First line at each clinical setting
First line in ES
Issues. First line at different clinical settings ES incessant VT multiple shocks first shock at ICD implant before ICD implant First line at each clinical setting
528 patients treated by ablation, 634 procedures were performed The first procedure was endocardial in 348 (66%), endo-epicardial in 156 (29.5%) and surgical in 21 (4.3%) Largest VT ablation study published ever
Risk classification
Acute results based on PVS 482 patients underwent post ablation PVS Inducibility was not tested in 46 pts (8.7%) because of absence of VT inducibility at baseline PVS (n=39) or severe acute complications (n=7). Class A : 371 patients (77%) Class B : 60 patients (12.4%) Class C : 51 patients (10.6%)
Freedom from VT recurrence VT recurred in 164 patients (34.1%) Median recurrence survival time was 44.2 months Class A : 28.6% Class B : 39.6% Class C : 66.7%
Survival from cardiac death 75 patients (15.6%) died 22 SCD 34 Heart failure 19 non cardiac death Class A : 8.4% Class B : 18.5% Class C : 22%
Survival from cardiac death
Issues. First line at different clinical settings ES incessant VT multiple shocks first shock at ICD implant before ICD implant First line at each clinical setting
Patients underwent ICD implantation for VF, unstable VT or syncope with inducible VT Reduction in VT episodes, from 33% to 12% in the ablation arm and appropriate ICD shocks decreased from 31% to 9%
Randomized patients with previous myocardial infarction, reduced ejection fraction ( 50%) and haemodynamically stable VT to catheter ablation or no additional therapy, apart from subsequent ICD. The rate of survival free from recurrent VT over 24 months was higher in the ablation group compared with the control arm [47% vs. 29%, HR 0.61 (95% CI 0.37, 0.99), P = 0.045].
first line first line
Issues. First line at different clinical settings ES incessant VT multiple shocks first shock at ICD implant before ICD implant First line at each clinical setting
Can we perform it before ICD implant?
Can we perform it before ICD implant even in the absence of VT?
Ablation strategies Ablation during SR Substrate modification, independently from the VT inducibility, focused on complete abolition of late and fragmented activity. 1. substrate map 2. programmed ventricular stimulation Pacemapping in areas with long St-QRS and 12 morphology match nontolerated VTs Ablation during VT Activation mapping and entrainment manoeuvres during the ongoing arrhythmia. Tolerated VTs
Activation mapping Substrate mapping Not let the VT get out
Absolute end-points Complete LPs abolition Absence of any VT inducibility
fused fragmented late double double & isolated late Isolated late Circulation 2012;125:2184-2196
Antonio Berruezo et al. Circ Arrhythm Electrophysiol. 2015;8:326-336
Recordings showing the 3 types of response observed during radiofrequency (RF) application (in sinus rhythm) at the conducting channel (CC) entrance when conduction block was obtained. Copyright American Heart Association, Inc. All rights reserved.
Inferior view of bipolar voltage electroanatomic substrate maps during sinus rhythm before (MAP) and after (remap) scar dechanneling in a patient with healed myocardial infarction. Copyright American Heart Association, Inc. All rights reserved.
Core Isolation of Critical Arrhythmia Elements for Treatment of Multiple Scar-Based Ventricular Tachycardias by Wendy S. Tzou, David S. Frankel, Timothy Hegeman, Gregory E. Supple, Fermin C. Garcia, Pasquale Santangeli, David F. Katz, William H. Sauer, and Francis E. Marchlinski
Core isolation (CI) was performed incorporating putative isthmus and early exit site(s) based on standard criteria.
Endo and epicardial unipolar scar were areas with a unipolar voltage <8 mv. We defined as unipolar penumbra area the unipolar scar beyond the bipolar LVA
MI without scar????
Although DS is not always identified in post-mi patients, its endocardial extension and density predict not only scar transmurality but also the presence of LPs either in the endocardium or in the epicardium.
Scar and EGM segmental analysis DS was the predominant bipolar voltage type in 14.3% of the segments and border zone in 20%. Endocardium LPs were present in 10% of the 1597 endocardial segments (in 5.2% fractionated LPs and in 4.8% isolated LPs) o Underlying DS in 60% and border zone in 33.8% EPs in 22.1% (in 19.3% fractionated LPs and in 2.8% isolated LPs) and o Underlying border zone in 67.7% and DS in 32.3% Normal EGMs in 66.8% of the segments In 1.1% of the segments there was diffuse dense scar. Epicardium LPs were present in 12.3% of the epicardial segments (in 2.2% fractionated LPs and in 10.1% isolated LPs) EPs in 13.5% (in 9.4% fractionated LPs and in 4.1% isolated LPs) Normal EGMs in 71.9% Diffuse dense scar in 2.2%. 120 100 80 60 40 20 0 Scar Normal Isolated LPs2 Fract EPs Isolated LPs Fract LPs Isolated LPs are found more commonly in the epicardium compared to endocardium (p=0.004) and any type of EPs in the endocardium as compared to the epicardium (p=0.003)
Focusing on the distribution of LPs in the 17-segment shell we exhibited a significant shift towards the inferolateral segments taking into account the whole study population
Prognostic Value of EAM Characteristics VT recurrence Cardiac death Increased unipolar scar exceeding bipolar LVA (penumbra) reflects diffuse disorganized myocyte loss and is associated with increased mortality, whereas endocardial LP presence improves prognosis possibly through a successful VT ablation procedure
Achievement of scar homogenization, beyond its subjective interpretation, necessitates an extended damage in the myocardium Electric scar isolation is unlikely to be universally feasible with current ablation technology Scar dechanneling and core isolation are relative to LP abolition and need verification LAVAs elimination is liable to a more subjective interpretation as with current EAM systems it is impossible to provide a complete annotation of presence and distribution of LAVAs before and after ablation.
Conclusions LPs abolition should constitute the primary target for substrate ablation because LPs abolition is a clear end-point amenable to objective evaluation and LPs are more closely related to clinical VT isthmuses EPs elimination should adjunctively be performed after a definite EP proof of their involvement in the VT circuit, in patients without LPs (especially those with septal scars) and in cases of persistent VT inducibility after LPs abolition. The development of an improved multipolar recording technology that can identify slow conduction entrances into the scar and allow observing dynamic changes in the slow conducting channels during ablation could allow reliable and prompt EP characterization and subsequent documentation of their disappearance post ablation.