NAAMA s 24 th International Medical Convention Medicine in the Next Decade: Challenges and Opportunities Beirut, Lebanon June 26 July 2, 2010 I have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. I will inform the audience of any off-label uses discussed. Name of Presenter: Walid Saliba, MD Affiliation/Financial Interest Grant/Research Support Consultant Speakers Bureau Organization (please list) Medtronic /SJM/BSX/BW
Management of Ventricular Tachycardia Approaches and Outcomes Walid Saliba, M.D. Director, Atrial Fibrillation Center Cardiac Electrophysiology & Pacing Department of Cardiovascular Medicine Cleveland Clinic
Triggered activity Mechanisms of VT Increased automaticity EADs DADs increased automaticity TdP idiopathic VT Reentry AIVR idiopathic VT MMVT (in SHD) V Fib
Ventricular Arrhythmias Structural Heart disease Ischemic ARVD, Sarcoidosis DCM: BBR-VT HOCM Annular VT (DCM) Idiopathic Outflow Tract VT ILV-VT VF Channelopathy Long QT, Brugada s syndrome
Scar related VT/VF (Ischemic)
Underlying Arrhythmia of SCA ~85% due to VT/VFib Primary VF 8% Torsades de Pointes 13% VT 62% Bradycardia 17% Adapted from Bayés de Luna A. Am Heart J 1989;117:151-159.
Ventricular Tachycardia Secondary Prevention of SCD: 60 Sustained VT/VF ICD (AVID, CASH, CIDS) Death Arrhythmic death 60 50 50 % 40 30 20 10 Amio ICD 0 0 1 2 3 4 5 6 Years 24% Decrease in total Mortality % 40 30 20 10 Amio ICD 0 0 1 2 3 4 5 6 Years 50% Decrease in sudden cardiac death
Ventricular Tachyarrhythmias 60% recurrent VT within the first year. Adjunctive treatment Antiarrhythmic drugs Catheter ablation Endocardial resection /aneurysmectomy
Antiarrhythmic Drugs for VT 15-30% efficacy in treating VT. Class III, I Decreases Arrhythmia Burden and ICD shock but is not protective against SCD. + Risk Of Proarrhythmia CAST, SWORD,EMIAT
Ventricular Tachyarrhythmias Adjunctive treatment Antiarrhythmic drugs Catheter ablation Endocardial resection /aneurysmectomy
VT Ablation Catheter ablation: 1. Patients with frequent ICD shocks 2. Patients with preserved LVEF and hemodynamically stable VT 3. Prophylactic therapy: SMASH VT, VTACH
Ischemic VT 72 year old male patient with old AMI, frequent ICD shocks for relatively slow VT.
Catheter Ablation of Reentrant VT in Setting of Ischemic Heart Disease Goal = Identification of critical isthmus of conduction that is part of reentrant circuit Exit: At the scar borderzone.
Ischemic VT: Activation Map 1 4 2 5 3 1. Mid diastolic potential 2. Concealed entrainement 6
ACTIVATION MAP AND CONCEALED ENTRAINMENT I AVF V1 V5 Abl 1-2 PACING Same Paced QRS morphology S QRS(70ms) = Eg QRS(70ms) PPI (530ms) ~ VTCL (530ms) S - QRS Return Cycle (PPI) VTCL Eg - QRS Activation Map
Ischemic VT: Ablation Long Term Success: 60-90%
Ablation Strategies : Scar Exploration Ablation during Sinus rhythm / Atrial pacing 1. Circumferential ablation (Borderzone) 2. Borderzone ablation at site of closest pacemapping 3. ILPs ablation within the scar area.
VT Ablation Channel exit site at the border of the scar # of Pts 24 Acute Success (%) 86 Chronic Success (%) 66
3-D nature of the VT circuit Ischemic VT Failure of the endocardial approach Sub-Epicardial Exit
Epicardial VT ablation: The role of the Underlying cardiac Substrate Improved success rate with epicardial VT ablation in NICM, ARVD. Less systematic data related to Ischemic VT. Epicardial in origin in 5% - 40%
913 VT Ablation from 3 Tertiary Centers Overall: 15% DCM: 30-40% ICM: 10% Prior endocardial ablation had failed in 86% of patients 15% Epicardial (n=156) 85% Endocardial Sacher et al. HRS 2009
ECG Recognition of Epicardial VTs ECG features suggesting Epicardial VT: Pseudodelta wave: 34 msec from QRS onset to beginning of earliest rapid deflection in V1-V6 Intrinsicoid deflection: QRS onset to Peak R wave in V2 85msec Precordial RS interval > 120 msec MDI: ID/QRSd 056 (Max Deflection Index) 34 msec 85msec > 120 msec Berruezo et al. Circ 2004:109.1842
66 y.o.; IHD; LVEF:25% Frequent ICD shocks Failed endocardial ablation
CCF--Epicardial Ablation of Ischemic VT July 1999 July 2008 712 patients referred for VT ablation 79 (11%) Epicardial Approach attempted. LVEF: 36±2 % (10%-66%); ICD: 63% Other 37% 12% 22% 30% No SHD Non-Ischemic HD Ischemic HD
Epicardial VT Abalaion: Outcomes Acute Success Inability to induce VT : 78% using similar induction protocol. Complications No Coronary complications. 0 RV perforation : (3%) Pericardial effusion (acute): (8%) Phrenic nerve paralysis: 1. Recovered at 6 months.
Prophylactic Catheter Ablation for the Prevention of ICD Therapy SMASH-VT ICD+Ablation vs. ICD alone Patients with a history of MI who received ICDs for the secondary prevention of sudden death. Reddy et al. NEJM 2007
VTACH Study Event Rate Endpoint Abl+ ICD ICD RR 95% CI ICD shock 17 / 54 (31.5%) 29 / 56 (51.8%) 0.61 0.38-0.97 Non-blinded study. N=54/56.. Primary endpoint: VF/ICD Rx. Prophylactic VT ablation results in a reduction in ICD discharge over a 27 month follow up Lancet 2009
Ventricular Fibrillation 41 year old female Episode of seizure Recurrent PMVT VF Cardiac Work up: Cardiac Cath: Nonobstructive CAD LVEF 45% Cardiac CT: No ARVD Underwent ICD Placement
EP Study: Target Initiating PVC s 240 ms 160 ms 50 Ablation catheter electrogram Saliba et al. Ventricular fibrillation: ablation of a trigger? JCE 2002
Ablative Therapy for Polymorphic VT Saliba et al. Ventricular fibrillation: ablation of a trigger? JCE 2002
Ablation of VF 27 pts with idiopathic VF First initiating beat of VF identical in morphology Early Coupling interval: (297 ± 41 ms to preceding beat) Haïssaguerre et al, Circulation 2002;106:962 967
VF: The Purkinje Potential VF storm is frequently initiated by monomorphic PVCs. These triggering PVCs appear to be related to PLPs Ablation of these PVCs can eliminate VF. Haissaguerre et al.. Circulation 2002
Outflow Tract VT
Outflow tract PVCs 30 y/o M with frequent PVCs since age 10, DCM progressive since age 13 -> LVEF 35% EPS/RFA RVOT PVCs -> LVEF 55% 3 months and 3 yrs afterwards T.C.
Outflow Tract VT Ablation Accessible from: RVOT Above the Pulmonic valve Aortic Cusps: Rt-LT LVOT Aorto-Mitral continuity Epicardial Superior MV annulus Distal CS: anterio crux
ICE : Aortic Valve NC R Ablation Catheter Aorta L LCC Aortic Valve
Outflow Tract VT/PVC s Frequency associated with CMP High success rate with Ablation
END