Download - Indications to ablation

Indications to ablation of ectopic beats from the outflow tract: the role of LV

enlargement, symptoms and arrhythmia burden

Dr. Gerardo Rodriguez DiezArrhythmias and pacing Unit

CMN 20 de Noviembre. ISSSTEMéxico D.F.

4 years old girl - with PVC’s since born

PVC’s from the Outflow

Tract

» Why do we performed ablation in this patient?

• Because her symptoms?

• Because decrease Ejection Fraction?

• Because she has dilated cardiomiopathy?

Before ablation

After ablation

Post Ablation - LVEF 60%

Pre Ablation – LVEF 35%

Mountantonakis S et al Heart Rhythm. 2011,8(10):1608-1614

61 (88%)success

↑↑EF by 14%

8 pts with VPDsNo EF ∆ on Max HF meds

2 pts (3%)recurrence

Reversal of PVC Induced LVCM

63 (91% success)

6 pts (9%)Close to coronary or Intramural

RF ablation

69 pts (EF-35 ±9%; LVDD

5.8 ± 0.7cm; 61 % -LVOT)

Role of ventricular enlargement

» Ventricular enlargment is very important in this pathology

» What is first?

• Cardiomiopathy becuase PVC’s

• PVC’s worsening a previous dilated heart

• Can we identify patients with PVC’s at risk for cardiomyopathy ?

• 43/57 - VPDs >24%

• 14/57 - VPDs < 24%• 16 +/-4% (10 - 21%)

• 25/117 with Normal EF with VPDs >24%

57 n = 174 pts117

U of Michigan Group(Bogun) Heart Rhythm, Vol 7 July 2010

PVC Burden and LV Function

•Sensitivity: 79%•Specificity: 78%

If exclude pts with PVCs < 10,000 then difficult to distinguish risk between 10-35%

• Can one identify patients with PVC’s at risk for cardiomyopathy/with reversible cardiomyopathy?

JACC 2013; 62(13)

25% of patients went out of ICD

Class 1 indication

80 pts34% Structural Heart Disease

PVC QRS Duration – Relationship to LV CM (90pts)

No LV Dysfunction (n=66)

Reversible LV Dysfunction(N=24)

Deyell M, Park K et a Heart Rhythm 9:1465-1472 2012

No difference in PVC amount(all >10,000/day) or location (RV/LV)

P<0.001158

135

PVCs may unmask some baseline fiber disruption and cause depressed function in predisposed patients?

VPD QRS Duration - >151ms 79% sensitivity; 91% specificity for LVCM


QRS duration >15382% Sensitivity 75% specificity

Carballeira L et al. Heart Rhythm 2014; 11:299-306

Stress system with RVA Pacing – QRS duration with pacing to improve specificity?

Can this information be applied prospectively to identify risk and ablate prophylactically?

QRS with RVA pacing >170ms

Park K, Deyell M et al Heart Rhtyhm 2012 abstract

Could we can identify patients with irreversible cardiomyopathy?

PVC QRS Duration – Outcome After Ablation (103pts)

No LV Dysfunction (n=66)

Reversible LV Dysfunction(N=24)

Partially reversible/Irreversible LV Dysfunction(N=13)

No difference in PVC amount(all >10,000/day) or location

P<0.002

P<0.001158

173

135


Best VPD Duration Cutoff for identifying irreversibility of PVC induced CM


JACC 2013 60(21) 2194-2204

SCAR

Normal Bipolar Electrogram

Synchronous depolarization

Normal

Infarcted

Low Amplitude Fractionated Electrograms

Discontinuous conduction with poor cell to cell coupling → Reentry

Bipolar Voltage Mapping - Identify Gross Scar (VT Substrate)

EndocardiumBipolar

EndocardiumUnipolar

EpicardiumBipolar

>1.0 mV

<0.5 mV

>8.3 mV

<0.7 mV

>1.5 mV

<0.5 mV

Normal6pts

NICM +VT

Endo Unipolar Egs to Identify Epicardial Scar

Hutchinson et al Circ Arrhythm Electrophysiol. 2011 Feb:4(1):49-55.

Normal Heart(17pts)

Anticipated Reversible VPD induced CM(14pts)

Irreversible CM (24pts)

No scar or small macro scar which was excluded

Campos B et al JACC 2013; 60:2194-2204

3 Patient Groups studied

1.2%

9.8%

58.8%

Bipolar vs Unipolar maps

Percent Area of Unipolar Abnormality Predicts Reversibility of LV Dysfunction

• Risk assessment?• Response to drug tx?• Response to bi V

pacing?

Campos B, et al JACC 2013 60(21) 2194-2204

• Frequent VPDs/NSVT• Common /under-recognized cause of reversible CM• Association with risk of reversible CM

> 13 000 PVCs threshold ? (13%)>153 QRS duration during PVC>170 ms QRS duration during RVA pacing

Identify risk - early ablation – Need prospective validation• Recognition of Irreversible CM

• QRS with PVC > 170ms• 190 RVA pacing(preliminary)• Unipolar Mapping – Uni Egs > 32% of LV surface area

Identifying Reversible Nonischemic Cardiomyopathy

Conclusion

Thank you very much for your attention!

¡Grazie Mille!