Acknowledgements Cardiomyopathy: Catheter Ablation and NIH Beyond - - PowerPoint PPT Presentation

9/8/2012 1

Management of VT in Non-ischemic Cardiomyopathy: Catheter Ablation and Beyond

Kalyanam Shivkumar, MD PhD FACC

UCLA Cardiac Arrhythmia Center & EP Programs UCLA Health System

Acknowledgements

• NIH
• NIH-Bioengineering Research Partnership
• American Heart Association
• DISCLOSURES:
• University of California (UCLA) Holds Patents

in This Area: catheter technology, embolism prevention technology, minimally invasive methods for cardiac interventions

Management of VT in Non-ischemic Cardiomyopathy

• Clinical Approach
• Pathophysiology
• Catheter Ablation
• Beyond Catheter Ablation

Willem Einthoven (Semarang, May 21, 1860 – Leiden, September 29, 1927)

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VTSO regions.MI

Adapted from: John Miller, MD , Univ of Indiana

Hutchinson MD, Marchlinski FE: Epicardial Ablation of VT in patients with non ischemic LV cardiomyopathy: Cardiac Electrophysiology Clinics, 2(1);93-103. 2010

Multiple VT’s with basal exits

Management of VT in Non- ischemic Cardiomyopathy

• Clinical Approach
• Pathophysiology
• Catheter Ablation
• Beyond Catheter Ablation

Causes of VT in NICM

• Scar based macroreentry
• BBR
• ‘Functional’ VT’s

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Leenen FHH: Circ Res 2007;101:221-223

ARRHYTHMIAS

FROM SCAR TO VENTRICULAR ARRHYTHMIAS

Neural Remodeling Myocardial Level

Courtesy: Peng-Sheng Chen MD and Michael Fishbein MD Ajijola OA & Shivkumar K: Neural Remodeling and Myocardial Infarction: The Stellate Ganglion as a Double Agent: Journal of the American College of Cardiology, Volume 59, Issue 10, 6 March 2012, Pages 962-964

REPONSE TO CARDIAC INJURY INVOLVES NEURAL REMODELING BEYOND THE HEART

Ajijola OA, Wisco J, Lambert W, Mahajan A, Stark E, Fishbein MC & Shivkumar K: Extra-Cardiac Neural Remodeling in Humans with Cardiomyopathy . Circulation Arrhythmias & Electrophysiology 2012 (in press).

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Management of VT in Non-ischemic Cardiomyopathy

• Clinical Approach
• Pathophysiology
• Catheter Ablation
• Beyond Catheter Ablation

Knowledge about VT Circuits: Limits of our Extrapolation of Knowledge from Post-MI

• MMVT Circuits Are Deep Within Scar: ICM >NICM
• Scar Border Zones Are Critical: NICM ±
• Late potentials an ‘electrical footprint’: ICM>NICM
• Clinical Imaging Is Providing New Insights
• Mapping Techniques Have Greatly Improved
• Epicardial vs Endocardial Scar: NICM>ICM
• 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 nonischemic cardiomyopathy and monomorphic ventricular tachycardia. Circulation. 2003;108(6):704-710. 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.

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Voltage Map-Anatomical Correlation: NICM

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

Epicardial Map: Non-Ischemic Cardiomyopathy

Normal ECG L I

Abl d Abl d Abl d

Border

Scar EPICARDIAL VOLTAGE MAP TARGETED VT

ELECTROGRAMS End

• Epi

RV His RA ICE

FLUOROSCOPY

1 mV

* *

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

Peri-Annular Scar

Non-Ischemic Cardiomyopathy: Epicardial ‘Scar’

Epicardial Voltage Map

Epi Endo

RV

His 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

Hutchinson MD, Marchlinski FE: Epicardial Ablation of VT in patients with non ischemic LV cardiomyopathy: Cardiac Electrophysiology Clinics, 2(1);93-103. 2010

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. J Am Coll Cardiol 2010;55(21):2355-2365

Examples Of Late Potentials: Moderate (mLP) and Very Late (vLP)

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

• f 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)

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

• f hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol 2010;55(21):2355-2365

P=0.012 P=0.0017 P<0.0001 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

• f hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol 2010;55(21):2355-2365

Differences In Scar Area And Late Potentials Between NICM And ICM

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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. Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation

• f hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol 2010;55(21):2355-2365

Cano O, Hutchinson M, Lin D, Garcia F, Zado E, Bala R, Riley M, Cooper J, Dixit S, Gerstenfeld E, Callans D, Marchlinski FE. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy. J Am Coll Cardiol. 2009;54(9):799-808. Kuhne M, Abrams G, Sarrazin JF, Crawford T, Good E, Chugh A, Ebinger M, Jongnarangsin K, Pelosi F, Jr., Oral H, Morady F, Bogun FM. Isolated potentials and pace-mapping as guides for ablation of ventricular tachycardia in various types of nonischemic cardiomyopathy. J Cardiovasc Electrophysiol. 2010;21(9):1017-1023. 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 Nonischemic Dilated Cardiomyopathy: Incidence, Characterization and Implications, Heart Rhythm (2011), doi: 10.1016/j.hrthm.2011.03.008.

Isolated Septal Substrate for NICM

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INTRA-SEPTAL VT : MAPPING AND ABLATION

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)

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)

INTRA-SEPTAL VT : MAPPING AND ABLATION

RVOT Septal Perforator 1 Septal Perforator 2

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)

Epicardial VT Originating from LV base in a patient with a VAD

UCLA Cardiac Arrhythmia Center

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

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Bipolar Linear Ablation Pen Isolator™ Atricure Inc, Cinncinnati OH

Surgical Access to LV base via lateral thoracotomy and Epicardial ablation with closed irrigated catheter and surgical ablation pen

VAD cannula Surgical Ablation Pen Closed Irrigated Catheter

CS His

VAD cannula Surgical Ablation Pen Closed Irrigated Catheter

CS His LMCA UCLA Cardiac Arrhythmia Center

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

Post-ablation Images of Epicardial Aspect of LV

UCLA Cardiac Arrhythmia Center

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

Management of VT in Non- ischemic Cardiomyopathy

• Clinical Approach
• Pathophysiology
• Catheter Ablation
• Beyond Catheter Ablation

Knowledge about VT Circuits: ICM vs NICM

• MMVT Circuits Are Deep Within Scar: ICM >NICM
• Scar Border Zones Are Critical: NICM ±
• Late potentials an ‘electrical footprint’: ICM>NICM
• Clinical Imaging Is Providing New Insights
• Mapping Techniques Have Greatly Improved
• Epicardial vs Endocardial Scar: NICM>ICM
• Interplay Between Structural VT And Functional

Components: NICM possibly> ICM

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Paolo Mascagni (1752-1815) Anatomia Universa:

The Autonomic Nervous System regulates all cardiac physiological functions

• Chronotropy (depolarization, repolarization)
• Dromotropy
• Inotropy
• Lusitropy

Sympathetic Modulation is Central to Pathogenesis of Arrhythmias Due to Structural and Functional VT’s (reentrant and non- reentrant…e.g. LQTS, CPVT)

CARDIAC SYMPATHETIC CONTROL

Vaseghi M, Ajijola A, Mahajan A, and Shivkumar K: Sympathetic Innervation, Denervation and Cardiac Arrhythmias ‘Cardiac Electrophysiology: From Cell to Bedside’ Zipes, D & Jalife, J, 6th ed. Elsevier, 2012

SYMPATHETIC MODULATION TO TREAT VENTRICULAR ARRHYTHMIAS

Vaseghi M, Ajijola A, Mahajan A, and Shivkumar K: Sympathetic Innervation, Denervation and Cardiac Arrhythmias ‘Cardiac Electrophysiology: From Cell to Bedside’ Zipes, D & Jalife, J, 6th ed. Elsevier, 2012

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Bourke T, Vaseghi M, Michowitz Y , Sankhla V, Shah M, Swapna N, Boyle NG, Mahajan A, Narasimhan C, Lokhandwala Y , Shivkumar K. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121(21):2255-2262.

CARDIAC SYMPATHETIC CHAIN IN HUMANS

Vaseghi M, Ajijola A, Mahajan A, and Shivkumar K: Sympathetic Innervation, Denervation and Cardiac Arrhythmias ‘Cardiac Electrophysiology: From Cell to Bedside’ Zipes, D & Jalife, J, 6th ed. Elsevier, 2012

Lower ½ LSG T2 T3 T4 Thoracic ganglia 2 cm Deflated lung 1st rib 2nd rib 3rd rib 4th rib Sympathetic chain

A B C

Anatomy and histology of left sympathetic chain

Bourke T, Vaseghi M, Michowitz Y , Sankhla V, Shah M, Swapna N, Boyle NG, Mahajan A, Narasimhan C, Lokhandwala Y , Shivkumar K. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121(21):2255-2262. Bourke T, Vaseghi M, Michowitz Y , Sankhla V, Shah M, Swapna N, Boyle NG, Mahajan A, Narasimhan C, Lokhandwala Y , Shivkumar K. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121(21):2255-2262.

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Effect of Thoracic Epidural Anesthesia (TEA)

Therapies before TEA Therapies during TEA

20 40 60 125

Number of Therapies

Effect of Left Cardiac Sympathetic Denervation (LCSD)

Bourke T, Vaseghi M, Michowitz Y , Sankhla V, Shah M, Swapna N, Boyle NG, Mahajan A, Narasimhan C, Lokhandwala Y , Shivkumar K. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121(21):2255-2262.

Stellate Control of the Heart

Randall W, Circ Res, 1968

Ajijola OA, Lellouche N, Bourke T, Tung R, Ahn S, Mahajan, Shivkumar K: Bilateral Cardiac Sympathetic Denervation For The Management Of Electrical Storm JACC 2012;59(1):91-92

BILATERAL STELLATE GANGLIONECTOMY FOR VT/VF STORM BILATERAL STELLATE GANGLIONECTOMY FOR VT/VF STORM

Ajijola OA, Lellouche N, Bourke T, Tung R, Ahn S, Mahajan, Shivkumar K: Bilateral Cardiac Sympathetic Denervation For The Management Of Electrical Storm JACC 2012;59(1):91-92

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SYMPATHETIC MODULATION TO TREAT VENTRICULAR ARRHYTHMIAS N E

Spinal Cord Thoracic T1-T4 RSG LS G

MACRO REENTRY FOCAL VF FUNCTIONAL VT AND VF

2/3 E 1/3 NE General Anesthesia TEA, SCS and Intrathecal clonidine Renal Denervation INTERVENTION NEURAXIAL LEVEL

Higher centers

Beta blockers

Vaseghi M, Ajijola A, Mahajan A, and Shivkumar K: Sympathetic Innervation, Denervation and Cardiac Arrhythmias ‘Cardiac Electrophysiology: From Cell to Bedside’ Zipes, D & Jalife, J, 6th ed. Elsevier, 2012

Ukena et al: Renal sympathetic denervation for treatment of electrical storm: first-in-man experience: Clin Res Cardiol (2012) 101:63-76

RENAL DENERVATION FOR THE MANAGEMENT OF VT STORM

MANAGEMENT OF VT IN NON-ISCHEMIC CARDIOMYOPATHY

Vaseghi M, Ajijola A, Mahajan A, and Shivkumar K: Sympathetic Innervation, Denervation and Cardiac Arrhythmias ‘Cardiac Electrophysiology: From Cell to Bedside’ Zipes, D & Jalife, J, 6th ed. Elsevier, 2012 Cardiomyopathy & Transplantation: Gregg C. Fonarow MD Tamara Horwich MD Daniel Cruz MD Arnold Baas MD Ann Hickey MD Mario Deng Ali Nsair MD ACHD: Ravi Mandapati MD Jamil Aboulhosn MD Pamela Miner RN NP Cardiac Surgery: Hillel Laks MD Murray Kwon MD Richard Shemin MD Peyman Benharash MD Curtis Hunter MD Sarika Jain MD* Santa Monica UCLA EP Eric Buch MD MS Jason Bradfield MD EP Nurse Practitioners: Shelly Cote RN MN NP Jean Gima RN MN NP Geraldine Pavez RN MN NP Radiology:

• J. Paul Finn MD

Stephen J. Kee MD John Moriarty MD Stefan Ruehm MD Administrative: Michelle Betwarda BS MHA Alissa Diaz BS Susana Morales Carmen Mora BS Karen Escobar BS Health System: Paul Watkins JD Michelle Betwarda BS MHA Johanna Bruner RN Erick Ascencio CVT Center Director Kalyanam Shivkumar MD PhD Co-Directors Noel G. Boyle MD PhD Ravi Mandapati MD Aman Mahajan MD PhD Director, Specialized Program for AF Eric F. Buch MD, MS Director, Specialized Program for VT Roderick H. Tung MD Director, Implanted Devices Clinic Osamu Fujimura, MD Director, Cardiac EP, UCLA Olive View Jason S. Bradfield MD WLA-VAMC: Zenaida Feliciano MD Malcolm Bersohn MD Janet Han MD Electrophysiology Faculty: Marmar Vaseghi MD MS William L Discepolo II MD Arby Nahapetian MD Joint Faculty Professor Sanjiv M. Narayan MD PhD Neurocardiology Program Olujimi A. Ajijola MD Marmar Vaseghi MD EP Fellows: Carlos Macias MD Anil Purohit MD Steven Stevens MD Daigo Yagishita MD PhD Echocardiography: Barbara Natterson MD Aman Mahajan MD PhD Cardiac Anesthesia: Komal Patel MD Johanna Schwarzenberger MD Jonathan Ho MD Jason Chua MD Ryan Crowley MD Ali Salehi MD

Coach John R. Wooden 1910-2010

*affiliate faculty

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Myocardial Scars and VT Circuits

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 NE

ACh

Spinal Cord Thoracic T1-T4 RSG LSG

EFFECTS OF AUTONOMIC REGULATION

MACRO REENTRY FOCAL VF FUNCTIONAL VT AND VF