9/8/2012 Management of VT in Non-ischemic Acknowledgements Cardiomyopathy: Catheter Ablation and • NIH Beyond • NIH-Bioengineering Research Partnership • American Heart Association Kalyanam Shivkumar, MD PhD FACC UCLA Cardiac Arrhythmia Center & EP Programs • DISCLOSURES: UCLA Health System • University of California (UCLA) Holds Patents in This Area: catheter technology, embolism prevention technology, minimally invasive methods for cardiac interventions Willem Einthoven (Semarang, May 21, 1860 – Leiden, September 29, 1927) Management of VT in Non-ischemic Cardiomyopathy • Clinical Approach • Pathophysiology • Catheter Ablation • Beyond Catheter Ablation 1
9/8/2012 Multiple VT’s with basal exits VTSO regions.MI Hutchinson MD, Marchlinski FE: Epicardial Ablation of VT in patients with non ischemic LV cardiomyopathy: Adapted from: John Miller, MD , Univ of Indiana Cardiac Electrophysiology Clinics, 2(1);93-103. 2010 Management of VT in Non- Causes of VT in NICM ischemic Cardiomyopathy • Scar based macroreentry • Clinical Approach • BBR • ‘Functional’ VT’s • Pathophysiology • Catheter Ablation • Beyond Catheter Ablation 2
9/8/2012 FROM SCAR TO VENTRICULAR ARRHYTHMIAS ARRHYTHMIAS Leenen FHH: Circ Res 2007;101:221-223 REPONSE TO CARDIAC INJURY INVOLVES NEURAL REMODELING BEYOND THE HEART Neural Remodeling Myocardial Level Ajijola OA, Wisco J, Lambert W, Mahajan A, Stark E, Fishbein MC & Shivkumar K: Extra-Cardiac Neural Remodeling Ajijola OA & Shivkumar K: Neural Remodeling and Myocardial Infarction: The Stellate Ganglion as a Double Agent: Journal of the in Humans with Cardiomyopathy . Circulation Arrhythmias & Electrophysiology 2012 (in press). American College of Cardiology , Volume 59, Issue 10 , 6 March 2012 , Pages 962-964 Courtesy: Peng-Sheng Chen MD and Michael Fishbein MD 3
9/8/2012 Knowledge about VT Circuits: Limits of our Management of VT in Extrapolation of Knowledge from Post-MI Non-ischemic Cardiomyopathy • MMVT Circuits Are Deep Within Scar: ICM >NICM • Scar Border Zones Are Critical: NICM ± • Clinical Approach • Late potentials an ‘electrical footprint’: ICM>NICM • Pathophysiology • Clinical Imaging Is Providing New Insights • Mapping Techniques Have Greatly Improved • Catheter Ablation • Epicardial vs Endocardial Scar: NICM>ICM • Beyond Catheter Ablation • Interplay Between Structural VT And Functional Components: NICM possibly> ICM Voltage map:non-ischemic cardiomyopathy Hsia HH, Callans DJ, Marchlinski FE. Characterization of endocardial electrophysiological substrate in patients with Hsia HH, Callans DJ, Marchlinski FE. Characterization of endocardial electrophysiological substrate in patients with nonischemic cardiomyopathy and monomorphic ventricular tachycardia. Circulation. 2003;108(6):704-710. nonischemic cardiomyopathy and monomorphic ventricular tachycardia. Circulation. 2003;108(6):704-710. 4
9/8/2012 Epicardial Map: Non-Ischemic Cardiomyopathy Voltage Map-Anatomical Correlation: NICM Epi * His End o ICE RA RV * FLUOROSCOPY ECG L I Normal Abl d Border 1 mV Abl d EPICARDIAL VOLTAGE Scar MAP Abl d Cesario D, Vaseghi M, Boyle NG, Fishbein MC, Valderrabano M, Narasimhan C, Wiener I and Shivkumar K. Value of High TARGETED VT density Epicardial and Endocardial Mapping for Catheter Ablation of Hemodynamically Unstable Ventricular Tachycardia. ELECTROGRAMS Heart Rhythm 2006 ;3:1-10 Cesario D, Vaseghi M, Boyle NG, Fishbein MC, Valderrabano M, Narasimhan C, Wiener I and Shivkumar K. Value of High density Epicardial and Endocardial Mapping for Catheter Ablation of Hemodynamically Unstable Ventricular Tachycardia. Heart Rhythm 2006 ;3:1-10 Non-Ischemic Cardiomyopathy: Epicardial ‘Scar’ Peri-Annular Scar Endo His Epi RV Epicardial Voltage Map Cesario D, Vaseghi M, Boyle NG, Fishbein MC, Valderrabano M, Narasimhan C, Wiener I and Shivkumar K. Value of High density Epicardial and Endocardial Mapping for Catheter Ablation of Hemodynamically Unstable Ventricular Hutchinson MD, Marchlinski FE: Epicardial Ablation of VT in patients with non ischemic LV cardiomyopathy: Tachycardia. Heart Rhythm 2006 ;3:1-10 Cardiac Electrophysiology Clinics, 2(1);93-103. 2010 5
9/8/2012 Examples Of Late Potentials: Moderate (mLP) and Very Late (vLP) . J Am Coll Cardiol 2010;55(21):2355-2365 Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K. Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol 2010;55(21):2355-2365 Endocardial (ENDO) and epicardial (EPI) electroanatomical LV voltage maps from a representative patient with nonischemic cardiomyopathy (NICM) Differences In Scar Area And Late Potentials Between NICM And ICM P<0.0001 P=0.012 P=0.0017 Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K. Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K. Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol 2010;55(21):2355-2365 of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol 2010;55(21):2355-2365 6
9/8/2012 Substrate Differences Between ICM and NICM Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K. Cano O, Hutchinson M, Lin D, Garcia F, Zado E, Bala R, Riley M, Cooper J, Dixit S, Gerstenfeld E, Callans D, Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation Marchlinski FE. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol 2010;55(21):2355-2365 tachycardia in left ventricular nonischemic cardiomyopathy. J Am Coll Cardiol. 2009;54(9):799-808. Isolated Septal Substrate for NICM Haqqani, H.M., Tschabrunn, C.M., Tzou, W.S., Dixit, S.,Cooper, J.M., Riley, M.P., Lin, D., Hutchinson, M.D., Garcia, F.C., Bala, R., Verdino,R.J., Callans, D.J., Gerstenfeld, E.P., Zado, E.S., Marchlinski, F.E., Isolated Septal Substrate for Ventricular Tachycardia in Kuhne M, Abrams G, Sarrazin JF, Crawford T, Good E, Chugh A, Ebinger M, Jongnarangsin K, Pelosi F, Jr., Oral H, Morady F, Nonischemic Dilated Cardiomyopathy: Incidence, Characterization and Implications, Heart Rhythm (2011), doi: Bogun FM. Isolated potentials and pace-mapping as guides for ablation of ventricular tachycardia in various types of 10.1016/j.hrthm.2011.03.008. nonischemic cardiomyopathy. J Cardiovasc Electrophysiol. 2010;21(9):1017-1023. 7
9/8/2012 INTRA-SEPTAL VT : MAPPING AND ABLATION INTRA-SEPTAL VT : MAPPING AND ABLATION S1 S2 Tholakanahalli V, Bertog S, Roukoz H & Shivkumar K: Catheter Ablation Of Ventricular Tachycardia Using Intracoronary Wire Mapping And Coil Embolization: Description Of A New Technique. 2012 (in revision) Tholakanahalli V, Bertog S, Roukoz H & Shivkumar K: Catheter Ablation Of Ventricular Tachycardia Using Intracoronary Wire Mapping And Coil Embolization: Description Of A New Technique. 2012 (in revision) RVOT Epicardial VT Originating from LV base in a patient with a VAD Septal Perforator 1 Septal Perforator 2 Mathuria NS, Vaseghi M, Buch E, Shivkumar K. Successful ablation of an epicardial ventricular tachycardia using a surgical ablation tool. Circ Arrhythm Electrophysiol . 2011;4:e84-86 Tholakanahalli V, Bertog S, Roukoz H & Shivkumar K: Catheter Ablation Of Ventricular Tachycardia Using Intracoronary Wire Mapping And Coil Embolization: Description Of A New Technique. 2012 (in revision) UCLA Cardiac Arrhythmia Center 8
9/8/2012 Surgical Access to LV base via lateral thoracotomy and Post-ablation Images of Epicardial Aspect of LV Epicardial ablation with closed irrigated catheter and surgical ablation pen Surgical Ablation Pen LMCA Closed Irrigated Catheter Closed Irrigated Catheter His Surgical Ablation Pen His CS VAD cannula CS VAD cannula Mathuria NS, Vaseghi M, Buch E, Shivkumar K. Successful ablation of an epicardial ventricular tachycardia using a surgical ablation tool. Circ Arrhythm Electrophysiol . 2011;4:e84-86 Mathuria NS, Vaseghi M, Buch E, Shivkumar K. Successful ablation of an epicardial ventricular tachycardia using a surgical ablation tool. Circ Arrhythm Electrophysiol . 2011;4:e84-86 UCLA Cardiac Arrhythmia Center Bipolar Linear Ablation Pen Isolator™ Atricure Inc, Cinncinnati OH UCLA Cardiac Arrhythmia Center Knowledge about VT Circuits: ICM vs NICM Management of VT in Non- ischemic Cardiomyopathy • MMVT Circuits Are Deep Within Scar: ICM >NICM • Scar Border Zones Are Critical: NICM ± • Clinical Approach • Late potentials an ‘electrical footprint’: ICM>NICM • Pathophysiology • Clinical Imaging Is Providing New Insights • Mapping Techniques Have Greatly Improved • Catheter Ablation • Epicardial vs Endocardial Scar: NICM>ICM • Beyond Catheter Ablation • Interplay Between Structural VT And Functional Components: NICM possibly> ICM 9
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