Epicardial VT Ablation The Cleveland Clinic Experience Walid Saliba, MD, FHRS Director, EP Lab Cardiac Electrophysiology Heart and Vascular Institute
Epicardial Access in the EP Lab Why Epicardial Special considerations: Access, Ablation and Complications Cleveland Clinic experience
LK 45 year old male with palpitations. Documented VT on ILR monitioring Failed prior endocardial VT ablation Investigations: Echo: mild LV dysfunction LVEF 45-50-% Non obstructive CAD Cardiac MRI: No LV/RV scars
Clinical VT: RBBB / LS axis
Endocardial Regional Mapping Not early
Now What? Decision to go Epicardial Failed Ablation EKG NICM Nothing interesting endocardial Anticoagulation Reversed Epicardial Access Obtained
Mid diastolic potential Epicardial Mapping
Coronary Angiography Prior to Ablation Away from coronaries: 5 mm Selective angiography Away from Phrenic nerve High amplitude pacing
Termination with Ablation RF open irrigated
Epicardial Ablation: Why ICM NDCM Arrhythmia Circuits can be deep Ablation lesion may not be that deep.
When do you go epicardial? The circuit is epicardial or mid-myocardial Defining the EKG Interval and Morphology Criteria Defining the substrate DCM, ARVC vs. ICM Journey to the endocardium has been futile Failed prior endocardial ablation No endocardial targets found Access to the endocardium not possible/dangerous Double mechanical valves Intramural thrombus
When do you go epicardial? The circuit is epicardial or mid-myocardial Defining the EKG Interval and Morphology Criteria
When do you go epicardial? The circuit is epicardial or mid-myocardial Defining the EKG Interval and Morphology Criteria Defining the substrate DCM, ARVC vs. ICM Need for epicardial ablation ICM: Less Frequent (10-15%) NICM: More frequent (30-50%) ARVC: Very Frequent (40-70%) Other: Brugada, sarcoid..? frequent
VT in DCM 1. The scar is greater on the epicardium than on the endocardium. 2. Most Scars localized to base of LV in the perivalvular region. Endo Map Epic Map >1.0 mv <0.5 mv
When do you go epicardial? The circuit is epicardial or mid-myocardial Defining the EKG Interval and Morphology Criteria Defining the substrate DCM, ARVC vs. ICM Journey to the endocardium has been futile Failed prior endocardial ablation No endocardial targets found Access to the endocardium not possible/dangerous Double mechanical valves Intramural thrombus
Epicardial Access, Navigation and Ablation
Subxyphoid Epicardial Access Puncture Site Anatomical Consideration
Tuohy Needle Access: Tools Epidural needle: 8.9 cm 17 Gauge Huber tip Quincke tip
Epicardial Puncture and Larrey s Space Not Too Low Not Too steep
Hematoma Intraabdominal Bleeding
Liver Puncture during Epicardial Catheter Ablation 53 y/o female with diagnosis of WPW, AF
Close Call
Inadvertent RV Puncture Up to 30% of cases Usually Self limited Usually benign if Single stick + No anticoagulation + No Sheathing.
Epicardial Access Successful Access: 95% Overall Failure due to adhesions Prior Open Heart Surgery: Successful in 20-80% Repeat access (5 months later) Successful in ~80% Other Issues Myocarditis-Pericarditis, Prior transmural MI
Localized Tamponnade because of Adhesions DCM, s/p ICD VT ablation Adhesions
Prior CABG surgery
Epicardial VT Ablation: What Can you access? Access available for the majority of the LV / RV epicardial surface. Limitations Can t access IV septum Papillary Muscles Epicardial LVOT (LV Summit)
LV Summit Activation Mapping 42 yo female with incessant NSVT Distal CS Aortic Cusps Epicardial
LV Summit VT
3D Mapping CS Epicardial LV RVOT Cusp
Ablation Distal CS: Transient success. (Limited energy) Epicardial: Transient effect LCC: No effect RVOT: No effect LVOT Under the valve: Transient effect (50W) LM Surgery Dissected under the LM Opened the ascending aorta Cryo from Epi and Endocardial regions
CCF--Epicardial Ablation July 2000 July 2017 2530 patients referred for VT ablation 260 (~11%) Epicardial Approach attempted. Age: 56±3 yrs (15-83); Male 73% LVEF: 36±2 % (10%-66%); ICD: 63% Sarcoidosis ARVD HOCM Brugada Other 12% 22% No SHD 37% 30% Non-Ischemic HD Ischemic HD
Changing patterns over the years More likely to go epicardial for DCM More likely to start epicardial with ARVC Less likely to go epicardial for Summit PVC/VT Consider pericardial access if large dense scar
Epicardial Mapping Incomplete Epicardial map 10% Adhesions Epicardial Mapping ONLY 10% Epicardial + Endocardial mapping (85%) Epicardial Before 20% Endocardial Before 65% Location of Target Site Epicardial 46% Endocardial 28% Epicardial and endocardial 26%
Procedure outcome (Acute) Acute Success: 78% Partial Success: 10% VT not targeted: 2% Failed: 9% Adhesions 14% Failed epicardial access 10% Endocardial sites better 49% Midmyocardial origin 12% Fat pad 5% Phrenic 3% Termination due to complication Other
Long Term Outcome Follow up : 13 months Mortality (30 days): 4.3% Freedom from VT/ICD shock: 42% Redo Procedures (VT Ablation): 8% (Results for the first 138 pts)
Complications Major* 6% Examples RV Perforation ~12% Coronary vessel injury (angiography done in 20% of cases) Pericardial vessel injury: Pericardial effusion Retained wire in diaphragm Diaphragmatic vessel injury: treated with Tx Phrenic nerve injury: resolved at 6 months *Death or requiring a procedure/intervention
Phrenic nerve injury Pacing Maneuvers Protective devices Balloon S V C A Ro A L V Catheter Buch et al. Heart Rhythm 2007; 4: 95-98
Delayed complications Coronary stenosis (>2 weeks) Mostly delayed stenosis related to media hyperplesia 10 x 4 months after RFA Pericarditis, Adhesions IP injection of steroids 2.0 mg/kg triamcinolone Triamcinolone 2 mg/kg
Conclusion Epicardial access is feasible with a high success rate Access may be limited secondary to prior surgery Ablation target are most frequently epicardial in Nonischemic Cardiomyopathy and ARVC. The decision to obtain early epicardial access depends on clinical suspicion: cardiac substrate, EKG and prior endocardial failure. Complications of Epicardial Ablation are relatively infrequent but tend to be severe when they occur Epicardial fat limits lesion size and mapping accuracy Surgical ablation in selected patients (LV summit, coronaries, intramural scar) Need for better tools
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