Post on 31-Mar-2018
transcript
Ventricular Tachycardia: Catheter Ablation
Who? How? When ? Results?
Vivek Y. Reddy, MD
Helmsley Trust Professor of Medicine
Director, Cardiac Arrhythmia Service
The Mount Sinai Hospital
vivek.reddy@mountsinai.org
Disclosures
• Grant support and/or Consultant:
– Abiomed Inc, Biosense-Webster Inc,
Stereotaxis Inc, St Jude Medical Inc
• I will be discussing off-label use of
catheter ablation devices.
Outline
• Scar-Related VT Ablation
• Outflow-Tract VT/PVCs
• Ventricular Fibrillation
Outline
• Scar-Related VT Ablation
• Outflow-Tract VT/PVCs
• Ventricular Fibrillation
Pathogenesis of Scar-Related VT
• Electrically-active live myocardial fibrils
traversing through the fibrotic tissue of the scar
EXCITABLE GAP
SCAR
EXCITABLE GAP
FUNCTIONAL BLOCK
SCAR
Post-MI VT: Catheter Ablation
• Post-MI VT is not a simple substrate with a single circuit
• Better to think of post-MI VT as an arrhythmogenic mass of tissue from which multiple VTs can emanate
• For clinical success need to treat not as circuits but as substrate Downar et al, JACC 1998
MV
1. Target Channels for Ablation
2. Target VT Exit Sites
Substrate Mapping & Ablation
ECG
Map
ECG
Map
1. Target Channels for Ablation
2. Target VT Exit Sites
Normal
Abnormal
3. Homogenize Scar
MV
Substrate Mapping & Ablation
Fre
edo
m f
rom
VT
The VISTA Trial
L.DiBiase et al, JACC 66:2872 (2015)
P < 0.001
Substrate Ablation of Unstable VTSingle & Multicenter Studies
• Marchlinski et al, Circulation 101:1288, 2000
• Soejima et al, Circulation 104:664, 2001
• Reddy et al, JACC 41:2228, 2003
• Kottkamp et al, JCE 13:675, 2003
Stevenson at al, Circulation 2009
Multicenter Thermocool VT Ablation IDE TrialLong-Term Outcomes
F.Marchlinski, C.Haffajee, J.Bashai et al, J Am Coll Cardiol 67:674 (2016)
VANISH: Post-MI VTRCT: AADs vs Catheter Ablation
JL.Sapp, GA.Wells, R.Prakash at al, NEJM 375:111 (2016)
Primary Prevention of ICD ShocksSMASH-VT
Preventative substrate ablation in preventing ICD shocks in post-MI pts who have sustained a VT/VF event (ie, 2°prevention ICD pts)
Follow-Up (2 years)
History of a MI
Cardiac Arrest
(VT/VF)
Randomization
ICD
ICD +
Substrate
Ablation
ICD Therapy
Fre
ed
om
fro
m IC
D R
x (
%)
Follow-Up (Months)
Ablation
Control
6 12 18 2400
20
40
60
80
10
0
(p = 0.003)
31.3 %
9.8 %
ICD Shocks
Reddy et al, NEJM, 357:2657 (2007)
ICD “Storm” Occurrence
• 6% vs 19%
• P = 0.06
Can catheter ablation reduce VT/VF
in post-MI patients undergoing ICD
implantation for stable VT?
Follow-Up (2 years)
History of a MI
Stable VT
LVEF < 50%
Randomization
ICD ICD +
Ablation
KH Kuck, et al, Lancet, 375:31-40 (2010)
Primary Prevention of ICD ShocksVTACH Study
Dinov B et al. Circulation 129:728-36 (2014)
Catheter Ablation in DCM-VTModerate Success (Compared to Post-MI VT)
VT-free Survival at 1 year:ICM = 57%, NICM = 40.5%
For DCM-VT, the only predictors of VT recurrence
were “Partial Success” or Failure.
Catheter Ablation in DCM-VTImproved Success with Scar Homogenization (?)
Göko�glan Y et al. J Am Coll Cardiol 68:1990-8 (2016)
The Difficult VT AblationCan we improve outcomes?
• Deep (Septal) Circuits
• Hemodynamic Support
• Bipolar RF
• EtOH Ablation
• Epicardial Ablation
• Neuraxial Modulation
Bogun at al, JACC 53:1138-45 (2009)
Mostly Intramural Scar:
What do you do?• Deep (Septal) Circuits
• Hemodynamic Support
• Bipolar RF
• EtOH Ablation
• Epicardial Ablation
• Neuraxial Modulation
The Difficult VT AblationCan we improve outcomes?
Bipolar Ablation
Clinical Case Example
Sequential Unipolar Bipolar Ablation
J.Koruth / S.Dukkipati / M.Miller / P.Neuzil / V.Reddy Heart Rhythm (2012)
DCM-VT: Septal Scar
The Difficult VT AblationCan we improve outcomes?
• Deep (Septal) Circuits
• Hemodynamic Support
• Bipolar RF
• EtOH Ablation
• Epicardial Ablation
• Neuraxial Modulation
• Deep (Septal) Circuits
• Hemodynamic Support
• Bipolar RF
• EtOH Ablation
• Epicardial Ablation
• Neuraxial Modulation
The Difficult VT AblationCan we improve outcomes?
• Deep (Septal) Circuits
• Hemodynamic Support
• Bipolar RF
• EtOH Ablation
• Epicardial Ablation
• Neuraxial Modulation
The Difficult VT AblationCan we improve outcomes?
Sternum
Liver
RV
LV
Modified from slide from: E Sosa, M Scanavacca, A d’Avila
ARVC-Related High Success of VT Ablation
• 17 Patients
• Mean f/u: 49 ± 21 mo
• Success rate: 88%
Epi/Endo Ablation
Reddy & Wilber, Manuscript in Preparation
RV EndocardiumVentricular Epicardium
TV
AP Burke, Medscape, http://emedicine.medscape.com
/article/1612324-overview
• Deep (Septal) Circuits
• Hemodynamic Support
• Bipolar RF
• EtOH Ablation
• Epicardial Ablation
• Neuraxial Modulation
Renal Denervation
Stellate Ganglionectomy
The Difficult VT AblationCan we improve outcomes?
Renal Denervation
RSDN for Ventricular ArrhythmiasOn-Going Clinical Trials
RESCUE-VT
Follow-Up
ICD Therapy
2º Prevention
1º Prevention + Inducible VT
ICD Implantation
Placebo RSDN
R
Renal Angiogram
• Deep (Septal) Circuits
• Hemodynamic Support
• Bipolar RF
• EtOH Ablation
• Epicardial Ablation
• Neuraxial Modulation
Renal Denervation
Stellate Ganglionectomy
The Difficult VT AblationCan we improve outcomes?
Bourke et al, Circulation, 2010;121:2255.
Stellate Ganglionectomy
Stellate Ganglionectomy Case SeriesICD Shocks: Left vs Bilateral CSD
Vaseghi et al, Heart Rhythm 11:360 (2014)
Success & Mortality After VT AblationEffect of Acute Inducibility: Mortality
P.Della Bella at al, Circulation 127:1359 (2013)
• 528 scar-VT patients treated with ablation
• Results of programmed stimulation:–Class A (Non-inducibility of any VT) 77%
–Class B (Inducibility of “non-clinical” VT) 12.4%
–Class C (Inducibility of “clinical” VT) 10.6%
Transplant/Mortality After VT AblationOutcome as a Function of Ablation Success
Transplant-Free Survival
Predictors of Transplant/Mortality
R.Tung, M.Vaseghi, DS.Frankel at al, Heart Rhythm 6:351 (2013)
Transplant/Mortality After VT AblationOutcome: Relationship to Functional Class
R.Tung, M.Vaseghi, DS.Frankel at al, Heart Rhythm 6:351 (2013)
Outline
• Scar-Related VT Ablation
• Outflow-Tract VT/PVCs
• Ventricular Fibrillation
Outflow-Tract VT
• Structurally-normal heart
• RVOT- or LVOT-VT
• ECG:
– Typically LBBB (or RBBB)
– Positive QRS in II / III / aVF
– QRS transition V3/V4
• Early transition LVOT
• Can be RBBB
• Not life-threatening
– [rare exceptions]
45 yo Fireman with OTVT ICDICD Interrogation
RVOT VT Ablation
RF on
Map
SBP
EC
G
What about PVCs?
Canine ModelBigeminal PVC Pacing vs Control
Huizar JF, et al. Circ Arry 2011;4:543-9.
Penela et al, JACC, 62:1195 (2013)
• 13% baseline PVC burden: 100% Sens / 85% Specificity to predict an absolute LVEF increase of 5% after catheter ablation
• 20 patients with Class I ICD indication no longer eligible at 6 months post-ablation.
Effect of PVC Ablation Prospective 4-Center Study (n=80 pts)
Lakkireddy et al, JACC 60:1531 (2012)
• 65 CRT Non-Responders with >10,000 PVCs/24h undergoing ablation• Age 66.6, 78% male, QRS duration = 155±18 msec• Acute and 12-mo success of ablation: 91% and 88%• Improvements in LVEF (26.2 32.7%, p 0.001)
– LVESD, LVEDD, LVESV, LVEDV, NYHA (3.0 to 2.0, p 0.001)
CRT Non-Responders Effect of PVC Ablation
Olgun et al, Heart Rhythm 8:1046 (2011)
Yokokawa et al, Heart Rhythm 9:92 (2012)
Yokokawa et al, Heart Rhythm 9:1460 (2012)
Predictors of PVC-CardiomyopathyInterpolated PVCs
• Interpolated PVCs– Higher risk for Cardiomyopathy
• Symptoms– Asymptomatic: HR = 13– Long duration (>60mo): HR=20
• QRS Width– QRS >150ms best predictive– Sens = 80% / Spec = 52%
Outline
• Scar-Related VT Ablation
• Outflow-Tract VT/PVCs
• Ventricular Fibrillation
– Focal Trigger Ablation
– Substrate Modification (Brugada)
Case: 16 yo, Normal LVEF, Syncope Exercise Treadmill Testing
ICD + BBL Shocks while riding a bicycle
Ventricular FibrillationFocal Triggers
Haissaguerre M, et al, Lancet (2012)
RVOT muscle
16%
Both foci in 4 pts
Purkinje 84%
LV dist
LV prox
Initiation of VF by “Purkinje beats”
Courtesy: Michel Haissaguerre
Case: Ablation
VF Triggers in Other Disease StatesChannelopathy & Post-MI
LQTS
Brugada
Brugada
Haissaguerre et al, Circ 108:925 (2003)
Bansch et al, Circ 108:3011 (2003)
VF Substrate Mapping in Brugada SyndromeNormal and Abnormal Epicardial Electrograms
K.Nademanee et al, Circulation 123:1270 (2011)
VF Substrate Mapping in Brugada SyndromeEffect of IV Flecainide
J.Brugada, C.Pappone, A.Berruezo et al, Circ Arry 8:1373 (2015)
Post-FlecainidePre-Flecainide
Brugada Syndrome: VF Substrate Ablation ECG Pattern During Follow-Up
J.Brugada, C.Pappone, A.Berruezo et al, Circ Arry 8:1373 (2015)
Baseline
Post-Flecainide
Pre-Ablation Follow-Up
Final Thoughts
• Scar-Related VT:– Ablation is safe!
– Ablation success is moderate in DCM
– ARVC-VT Ablation: Excellent Outcome
• Outflow-Tract VT
– Recognize it! ICDs are not indicated
– PVCs – When to intervene?
• Symptoms
• Ventricular Dysfunction / Dilatation
• High burden??
• Ventricular Fibrillation
– PVC Triggers
– Brugada Syndrome: Substrate Ablation