9/14/2019 William G Stevenson, MD Arrhythmogenic RV • Disclosures Cardiomyopathy: Ablation Therapy – Honoria • Abbott • Biotronik William G. Stevenson, MD • Boston Scientific • Medtronic Professor of Medicine – Intellectual Property Vanderbilt University Medical Center • Patent for irrigated needle ablation consigned to Brigham Hospital Nashville, Tennessee USA VanderbiltHeart.com Young adult college student • Collapses playing basket ball – AED shock – prolonged coma, hypothermia – complete recovery • No family hx of sudden death or cardiomyopathy • Echocardiogram normal – Subcutaneous ICD implanted – metoprolol 50 mg daily Genetic testing: PKP2 mutation 1
9/14/2019 Mapping and Ablation of scar- related VTs Young adult college student Induce VT / confirm diagnosis Sinus rhythm electrograms - Voltage Map - late potentials Substrate Mapping in Sinus Rhythm • 6 months later - fractionated potentials – S-ICD shock while standing talking, calls EMTs Place catheter at likely VT site Pace-mapping – EMTs observe VT that degenerates to VF - VT exits Unexcitable scar • 21 min of resuscitation Initiate VT - Slow conduction – treated with hypothermia • prolonged intubation, pneumonia, rhabdomyolysis Stable VT Unstable VT entrainment - entrainment once – Discharged on amiodarone and metoprolol electrograms - possible RF for termination Ablation of isthmuses / exits Ablation of isthmuses / exits during sinus rhythm during VT Baseline RVOT 400/2 induces a long run of spontaneously VT - 1 terminating VT 2
9/14/2019 RVOT 600/3 induces VF RV endocardial bipolar map 1.5 mv LAO AP Bipolar endocardial bipolar map with RF lesion sites VT-1 Pace-map 3
9/14/2019 RV Endocardium Variations in ARVC Bipolar EPS after endo substrate map: • Disease starts in the epicardium and progresses inward VF with RVOT 400/3 – Limited disease: • endocardial voltage may be normal Epicardium • predominantly epicardial ablation required – Moderate disease • epicardial low voltage areas >> endocardial • predominantly epicardial ablation + some endocardial – Advanced disease • epicardium may be largely fibrosis with no areas of capture • endocardial ablation often required • LV involvement – basal lateral most common: RBBB configuration VT – Recurrence rates may be higher Berruezo Europace 2016 Epicardial fractionated potentials pace-map with S-QRS delay Unipolar endocardial voltage Epicardial bipolar voltage Endocardial Epicardial Unipolar < 5.3 mv Bipolar < 1.3 mv 4
9/14/2019 Propagation Bipolar Voltage VT - 2 Multiple VTs in ARVC originating from EPS post epicardial ablation I RV scars along the tricuspid annulus isoproterenol 4 mcg/min II VT - 3 III I V1 II III V5 V1 VT - 1 I V5 II III V1 RF lesions through exit regions encircling the scar V5 5
9/14/2019 Arrhythmogenic RV Cardiomyopathy: arrhythmia substrate typically more extensive and pronounced in the epicardium: epicardial ablation improves outcomes Ablation targeted channels of relatively higher voltage through low voltage areas with isolated potentials In 11 pts: 1 recurrent VT over 6 – 24 mo FU RV Endocardium Epicardium Bi et al Circulation Arrhythmia Electrophys 2011; 4:478 Berreuzo et al Circ AEP 2012 Ablation compared with drug therapy for recurrent ventricular tachycardia in Ablation compared with drug therapy for recurrent ventricular arrhythmogenic right ventricular cardiomyopathy: Results from a multicenter study tachycardia in arrhythmogenic right ventricular cardiomyopathy: Mahida et al Heart Rhythm 2019 16, 536-543 DOI: (10.1016/j.hrthm.2018.10.016) Results from a multicenter study First ablation procedure vs drug Last ablation procedure (34% epicardial ablation) Endocardial only vs Endo + Epi Mahida et al Heart Rhythm 2019 16, 536-543 DOI: (10.1016/j.hrthm.2018.10.016) Endo + epi • 110 patients with ARVC and > episodes of sustained VT 71% VT free at 3 yrs − Initial therapy: antiarrhythmic drugs Endo only − Catheter ablation: ⚫ Endocardial only: 21 patients ⚫ Endo/Epi: 11 patients Procedure complications 4%: tamponade, MI, DVT 6
9/14/2019 Long-Term Outcome With Catheter Ablation Safety, long-term outcomes and predictors of recurrence after of VT in Patients With ARVC first-line combined endoepicardial VT substrate ablation in 121 procedures in 62 patients arrhythmogenic CM... A prospective multicentre study.. Pasquale Santangeli et al. Circ Arrhythm Electrophysiol. 2015;8:1413-1421 Berruzo Europace 2016 • 41 patients having first-line endoepicardial VT substrate ablation. Freedom from VT after multiple procedures • Ablation targeted low voltage areas (LVA) having electrograms with delayed components. • Epicardial LVA was larger than endo in all cases (103 +/- 79 vs. 19 +/- 24 cm2; P< 0.001). • Larger endocardial bipolar areas LVA were associated with smaller epicardial arrhythmogenic areas. • Complications: 1 death from tamponade after epicardial puncture. • Abolition of all inducible VTs was achieved in 90% (36 patients). • After 32 +/- 22 months, recurrent VT: 27% of patients • Plot showing the frequency of ventricular VT Left-dominant AC was associated with an increased risk of recurrence (HR = during the year before (blue lines) and after 3.41 [1.1-11.2], P= 0.044; log-rank P= 0.021). (red lines) for 49 patients with ICDs before and after ablation. Scientific Statement: Treatment of ARVC Nonischemic VTs treated with Catheter Ablation: Corrado et al Circulation 2015 Freedom from death, transplant or hospitalization for VT • Catheter ablation of VT is recommended in ARVC: – incessant or frequent despite maximal pharmacological therapy, including amiodarone (class I). ARVC – frequent VT that has failed pharmacological therapy other than Congenital HCM amiodarone (class IIa). Dilated CM – incessant VT or frequent VT that has not failed pharmacological Valvular therapy (class IIb). – first choice therapy without a back-up ICD for selected patients with drug-refractory, haemodynamically stable, single-morphology VT Sarcoidosis (class IIb). • An epicardial approach to VT ablation is recommended in patients who fail one or more endocardial attempts • An initial combined endocardial/epicardial approach should be considered, provided that the operator and laboratory are experienced. • Catheter ablation is not recommended as an alternative to an ICD for BWH 1999 – July 2010 Study Month Tokuda et al Circ Arrhythmia Electrophys 2012 prevention of SCD (class III). 7
9/14/2019 Thank You Nashville 8
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