Epicardial Approach to Mapping and Ablation of VT: Clinical and ECG Predictors of Epicardial Location Mathew D. Hutchinson, MD, FACC, FHRS Perelman School of Medicine University of Pennsylvania
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Outline Epicardial substate in specific disease states Preoperative MR and ECG clues Intraoperative mapping and imaging clues
Endo PM Epi Infarct Location Subendocardial Circuit Subepicardial Circuit RF Lesion Anterior (N=14) 100% 14% Healthy Inferior (N=14) 71% 36% Non-ablated Substrate Josephson et al. Circulation 1982; 66: 1199-204 Kaltenbrunner et al. Circulation 1991; 84:1058-71 Epi
13% total 68% 48% 6% total 39% also required endo RF Sarkozy et al. Circ Arrhyth Electrophysiol 2013; 6:1115-22 Tung et al. Heart Rhythm 2013; 10: 490-8
22 suspected Epi (20 prior endo RF) Epi vs. Endo scar 82% vs. 54% 55.3± 33.5 cm2 vs. 22.9± 32.4 cm 2 Wide, split or late pots - 50% Soejima et al. J Am Coll Cardiol 2004; 10:1834-42 Cano et al. J Am Coll Cardiol 2009; 54:799-808
>1.5 mv >1.0 mv <0.5 mv <0.5 mv 38 ± 32 cm 2 95 ± 47 cm 2 13 pts: Mean 2.2 prior endo procedures Epi RF adjacent to normal or ineffective endo regions in 76% Long term VT freedom 77-91% Epi-endo vs. endo (Bai): 85 vs. 52% at 3 yrs Garcia et al. Circulation 2009; 120:366-375 Thiene et al. Cardiovasc Pathol 2001; 10:109-17 Berruezo et al. Circ Arrhythm Electrophysiol 2012; 5:111-121 Bai et al. Circ Arrhythm Electrophysiol 2011; 4:478-485
>1.5 mv >5.5 mv >1.0 mv <0.5 mv <0.8 mv <0.5 mv 23 Pts Task Force Criteria ARVC 91% EAM vs. 39% CMR scars present Marra et al. Circ Arrythm Electrophysiol 2012; 5:91-100 Sensitivity Specificity PPV NPV Accuracy EA Scar 91 100 100 90 95 RV DGE 39 100 100 56 66 LV DGE 78 100 100 78 88
HCM LV 10 patients: all men, 57±9 yo, EF 57±13% Phenotype: 5 ASH, 5 mid cavity (3 apical aneurysm) Bipolar scar Endo/Epi 5, Epi 3, Endo 1 Apex 7/9, Lat 3/9, Ant-Lat 3/9, Inf 1/9 Dukkipati et al. Circ Arrhythm Electrophysiol 2011; 4:185-194
DGE CMR in Nonischemic CM 29 consecutive pts 19 VT pts, all with DGE 42% 14/29 with DGE (3 sarcoid) 7/14 endo 2/14 epi 47% 5/14 intramural Bogun et al. J Am Coll Cardiol 2009; 53:1138-45 Piers et al. Circ Arrhythm Electrophysiol 2013; 6: 875-83
Isolated Septal Substrate Relatively uncommon (11.3%) 9/30 normal bipolar, all with unipolar low voltage 80 ± 36 cm 2 LV 72 ± 51 cm 2 RV Epi approach limited utility Patchy, smaller area of scar Often adjacent to coronary vasculature Haqqani et al. Heart Rhythm 2011 8:1169-76 I II III avr avl avf V1 V2 V3 V4 V5 V6
Epi Endo Epicardial ECG Criteria- Ischemic CM 90% ischemic 0% ischemic; 67% NICM Sensitivity Specificity Pseudo Delta Pseudodelta wave 34ms 83% 95% 74 ±32 ms vs. 50±23 ms 96% 29% Intrinsicoid deflection time 87% 90% 85ms (V2) 72±46 ms vs. 63±36 ms 39% 24% Shortest RS complex 121ms 76% 85% 127 ±37 ms vs. 98 ±32 ms 53% 29% Intrinsicoid Deflection Time Berruezo et al. Circulation 2004; 109:1842-1847 Bazan et al. Heart Rhythm 2007; 4:1403 1410 Martinek et al. J Cardiovasc Electrophysiol 2012; 23:188-93 Shortest RS Complex
Epicardial ECG Criteria- LV EPI ENDO EPI ENDO I II III avr avl avf Anterior LV I I II III avr avl avf V1 V2 V3 V4 V5 Inferior LV V1 V2 V3 V4 V5 V6 III avf II V6 Bazan et al. Heart Rhythm 2007; 4:1403 10
Epicardial ECG Criteria- RV RV Inferior Wall RV Free Wall II V2 LV V6 III EPI ENDO RV V4 V5 avf V3 V1 V2 EPI ENDO Bazan et al. Heart Rhythm 2006; 3: 1132-9
>1.5 mv LV <0.5 mv Pericardium LV Bala et al. Circ Arrhythmia Electrophysiol. 2011 4:667-73
ENDO BIP >1.5 mv ENDO UNI >8.3 mv EPI BIP >1.0 mv <0.5 mv <0.5 mv <0.5 mv ENDO UNI EPI BIP DGE MR Unipolar Nonoverlap Unipolar- Bipolar Overlap M-M DE Normal ENDO Hutchinson et al. Circ Arrythm Electrophysiol 2011; 4:49-55 Normal EPI
Adjusting Unipolar Threshold 8.3 mv 9.4 mv 10.5 mv
VT1 VT2 Endo PM Endo LAT Bipolar Unipolar
34 ms >1.0 mv -139 ms <0.5 mv Base RAO Apex >1.5 mv <0.5 mv
Transmural Circuits in LVCM EPI ENDO Epicardial Isthmus Site Endocardial Exit Site
82 yo M with ICM, EF 20% IMI 1989, CABG 2010 Failed 2 previous endocardial ablations Recurrent slow VT, shocks 464 460 Termination >60sec PM Pap 478 460 464 460
PLV 513 498 GCV LV LV PLV PM
Summary CMP phenotype predicts EPI substate: ARVC/D >LVCM (inf/lat scar) > ICM Failure of endo ablation remains best predictor of need for epi procedure ECG predictors for epi VT origin are disease-specific CMR, voltage mapping, and ICE provide clues to the presence of epicardial scar
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