1 9/14/2019 Mapping and Ablation of scar- related VTs Young adult - - PDF document

9/14/2019 1 Arrhythmogenic RV Cardiomyopathy: Ablation Therapy

William G. Stevenson, MD Professor of Medicine Vanderbilt University Medical Center Nashville, Tennessee USA

VanderbiltHeart.com

William G Stevenson, MD

• Disclosures

– Honoria

• Abbott
• Biotronik
• Boston Scientific
• Medtronic

– Intellectual Property

• Patent for irrigated needle ablation consigned to Brigham Hospital

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

9/14/2019 2 Young adult college student

• 6 months later

– S-ICD shock while standing talking, calls EMTs – EMTs observe VT that degenerates to VF

• 21 min of resuscitation

– treated with hypothermia

• prolonged intubation, pneumonia, rhabdomyolysis

– Discharged on amiodarone and metoprolol Mapping and Ablation of scar- related VTs

Induce VT / confirm diagnosis Substrate Mapping in Sinus Rhythm

Pace-mapping

• VT exits

Unexcitable scar

• Slow conduction

Initiate VT Stable VT entrainment electrograms Ablation of isthmuses / exits during sinus rhythm Ablation of isthmuses / exits during VT

Sinus rhythm electrograms

• Voltage Map
• late potentials
• fractionated potentials

Place catheter at likely VT site Unstable VT

• entrainment once
• possible RF for termination

Baseline RVOT 400/2 induces a long run of spontaneously terminating VT

VT - 1

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RVOT 600/3 induces VF

RV endocardial bipolar map

1.5 mv

AP LAO

Pace-map

VT-1

Bipolar

endocardial bipolar map with RF lesion sites

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EPS after endo substrate map: VF with RVOT 400/3

Bipolar

Variations in ARVC

• Disease starts in the epicardium and progresses inward

– Limited disease:

• endocardial voltage may be normal
• 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

RV Endocardium Epicardium

Berruezo Europace 2016 Unipolar < 5.3 mv Endocardial Epicardial Bipolar < 1.3 mv Unipolar endocardial voltage Epicardial bipolar voltage

Epicardial fractionated potentials pace-map with S-QRS delay

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Propagation Bipolar Voltage

EPS post epicardial ablation isoproterenol 4 mcg/min

VT - 1

I II III V1 V5 I II III V1 V5 I II III V1 V5

VT - 2 VT - 3

Multiple VTs in ARVC originating from RV scars along the tricuspid annulus

RF lesions through exit regions encircling the scar

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Berreuzo et al Circ AEP 2012 Ablation targeted channels

• f relatively higher voltage

through low voltage areas with isolated potentials In 11 pts: 1 recurrent VT

• ver 6 – 24 mo FU

Arrhythmogenic RV Cardiomyopathy: arrhythmia substrate typically more extensive and pronounced in the epicardium: epicardial ablation improves outcomes

RV Endocardium Epicardium

Bi et al Circulation Arrhythmia Electrophys 2011; 4:478

Mahida et al Heart Rhythm 2019 16, 536-543 DOI: (10.1016/j.hrthm.2018.10.016)

Ablation compared with drug therapy for recurrent ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy: Results from a multicenter study

• 110 patients with ARVC and > episodes of sustained VT

− Initial therapy: antiarrhythmic drugs − Catheter ablation:

⚫ Endocardial only: 21 patients ⚫ Endo/Epi: 11 patients

Mahida et al Heart Rhythm 2019 16, 536-543 DOI: (10.1016/j.hrthm.2018.10.016)

Ablation compared with drug therapy for recurrent ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy: Results from a multicenter study First ablation procedure vs drug

(34% epicardial ablation)

Last ablation procedure Endocardial only vs Endo + Epi

Endo only Endo + epi 71% VT free at 3 yrs

Procedure complications 4%: tamponade, MI, DVT

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Safety, long-term outcomes and predictors of recurrence after first-line combined endoepicardial VT substrate ablation in arrhythmogenic CM... A prospective multicentre study.. Berruzo Europace 2016

• 41 patients having first-line endoepicardial VT substrate ablation.
• 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
• Left-dominant AC was associated with an increased risk of recurrence (HR =

3.41 [1.1-11.2], P= 0.044; log-rank P= 0.021).

Plot showing the frequency of ventricular VT during the year before (blue lines) and after (red lines) for 49 patients with ICDs before and after ablation.

Pasquale Santangeli et al. Circ Arrhythm Electrophysiol. 2015;8:1413-1421

Long-Term Outcome With Catheter Ablation

• f VT in Patients With ARVC

121 procedures in 62 patients

Freedom from VT after multiple procedures

Scientific Statement: Treatment of ARVC

Corrado et al Circulation 2015

• Catheter ablation of VT is recommended in ARVC:

– incessant or frequent despite maximal pharmacological therapy, including amiodarone (class I). – frequent VT that has failed pharmacological therapy other than amiodarone (class IIa). – incessant VT or frequent VT that has not failed pharmacological therapy (class IIb). – first choice therapy without a back-up ICD for selected patients with drug-refractory, haemodynamically stable, single-morphology VT (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

prevention of SCD (class III).

Dilated CM ARVC Sarcoidosis HCM Congenital Valvular Study Month

Nonischemic VTs treated with Catheter Ablation:

Freedom from death, transplant or hospitalization for VT

BWH 1999 – July 2010 Tokuda et al Circ Arrhythmia Electrophys 2012

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Thank You

Nashville