9/29/16 Ablation of Ventricular Tachycardia: Conflicts Indications for Use of Endocardial and Epicardial Approaches Ø Biosense-webster: research grant, honoraria Ø Medtronic: research grant, honoraria Ø St Jude Medical: research grant, honoraria Ø Boston scientific: honoraria Edward P Gerstenfeld MD Ø Rhythm diagnostic systems: advisory board Professor of Medicine University of California, San Francisco UCSF VT Ablation in Post-infarction Anatomic Substrate in Post-Infarction VT Cardiomyopathy Slow conduction in the infarcted tissue, with ‘zigzag' course of activation Catheter ablation increased from 2.8% (2002) à 10.8% (2011) (p <0.001). N =81,539 Palaniswamy C. Heart Rhythm 2014;11:2056 deBakker J. Circulation 1988; 77:589 Tung R. Circulation 2011;123:2284 1
9/29/16 Mapping VT in CAD VT Ablation in 57 yo with VT 7 years s/p ASMI Post-infarction Cardiomyopathy I II III Ø 90% macroreentrant, scar based aVR aVL * Ø 10% focal (automatic or triggered)* aVF V 1 * Ø Tolerated VT – entrainment mapping Inner Loop V 2 * V 3 Ø Non-tolerated VT – substrate based ablation V 4 V 5 V 6 480ms 480ms Ablds Ablpx *Das et al Heart Rhythm 2010;7:305-11 RVa VT Termination with RF Outcome After Ablation of Mappable VT I II III Arrhythmia recurrence AVR AVL AVF V 1 V 2 28% V 3 V 4 V 5 V 6 Abl d Abl p His d His p RV Stim Soejima et al Circulation 2001;104:664-669 2
9/29/16 Bipolar LV Voltage Map After Anterior MI But…. normal >1.5 mV • Only ~10% of VTs are tolerated normal <0.5.mV scar border scar Late potentials AP LAO Pacemaps matching VT VTACH Study Case Ø 107 pts. with stable VT, prior MI and LVEF<50% prospectively Ø A 64 yo male with HTN suffers an anterior MI 7 years ago randomized to ICD or VT RFA + ICD Ø Treated with ASA, metoprolol, lisinopril Ø Entrainment, activation, pace-mapping, substrate modification Ø Echocardiogram with EF 40% Ø Now presents to ER with VT. Cardioverted. Do you recommend: 47% a) Implant ICD 29% b) Amiodarone 200mg qd + ICD c) Catheter ablation + ICD Kuck et al. Lancet 2010;375:37-40. 3
9/29/16 Case Case Ø A 68 yo male has a history of AMI and VT Ø Single chamber ICD placed Ø Treated with ASA, metoprolol, ramipril, amiodarone 200mg qd Ø Echocardiogram with EF 30-35% Ø Presents with 2 appropriate ICD shocks for MMVT Ø Cath: no new coronary artery disease Do you recommend: a) Implant ICD Do you recommend: b) Amiodarone 200mg qd + ICD a) Reload and increase amiodarone to 400mg qd c) Catheter ablation + ICD b) Add Mexiletine 150mg tid c) Catheter ablation d) Transplant evaluation Ventricular Tachycardia Ablation or Escalated Ventricular Tachycardia Ablation or Escalated Drug Therapy ( VANISH ) Drug Therapy ( VANISH ) Ø Pts with ICM + VT randomized to escalated AAD therapy (Amio No Baseline Amio Baseline Amio > 200mg, I amio if<300mg, or + Mexiletine) vs. cath RFA Ø Primary outcome: death, VT storm, or appropriate ICD shock N=259- 132 Abl vs. 127 AAD Primary outcome = 59.1% (RF group) Vs. 68.5% (Esc- AAD group) Complications: RFA: 2 perforations, 3 bleeding Esc-AAD: 2 deaths pulm toxicity and 1 death hepatic toxicity Sapp J. N Engl J Med, 2016. 375(2):111-121. Sapp J. N Engl J Med, 2016. 375(2):111-121. 4
9/29/16 Case VT Ablation in NICM Ø Catheter ablation increased from 27% (1999-2002) to 35% (2003-2006) (P=0.06) UCLA: 6/2004-7/2011 Do you recommend: a) Reload and increase amiodarone to 400mg qd b) Add Mexiletine 150mg tid c) Catheter ablation d) Transplant evaluation Sacher F. Circ Arrhythm Electrophysiol 2008;1;153 Nakahara S. JACC 2010;55:2355–2365 Outcomes in VT Ablation in Nonischemic vs Ischemic Cardiomyopathy Non-ischemic Heart Centre of Leipzig VT (HELP-VT) Study Cardiomyopathy VT–Free Survival N=227: 63 NIDCM vs 164 ICM Ø Most common mechanism still reentrant MMVT Ø Automatic VTs also may also occur – effect of sedation/general anesthesia 57% ICM Ø Often multiple VTs, poorly tolerated 43% 40.5% Ø More often basal, perivalvular and epicardial origin NICM 23% Dinov B. Circulation. 2014;129:728-736 5
9/29/16 Septal Substrate for VT in Nonischemic Cardiomyopathy Why is Ablation More Difficult / Ø ~12% of NICM patients had isolated septal substrate, Less Successful in LV DCM multiple unmappable VTs Bipolar 1. Multiple VT morphologies 2. Epicardial / midmyocardial substrate Unipolar Haqqani, H. Heart Rhythm, 2011; 8:1169 Hutchinson M. Card EP Clin, 2010; 2:93 Scar Patterns in Nonischemic Subxyphoid Puncture– Cardiomyopathy Epicardial Catheter Ablation Sternum RAO RV Liver LV LAO Sosa E JACC 2000;35:1450-52 Piers, S. Circ Arrhythm Electrophysiol. 2013;6:875 6
9/29/16 Epicardial Access Epicardial Mapping RAO LAO RAO LAO When to Consider When to Consider Epicardial Access Epicardial Access • Substrate • Substrate – ARVC, DCM, Chagas, prior pericarditis – DCM, ARVC, Chagas, prior pericarditis • ECG • ECG – Inferior q waves, precordial pattern break – Inferior q waves, precordial pattern break • Imaging • Imaging – MRI, ICE – MRI, ICE • Patient characteristics • Patient characteristics – Age, comorbidities, prior CABG/valve surgery, – Age, comorbidities, prior CABG/valve surgery, pectus, hepatic enlargement pectus, hepatic enlargement 7
9/29/16 Epicardial VT Ablation After Failed 38 yo with ARVC and ICD Shocks Endocardial Ablation - Substrate (N=177) 4 >1.5 mV 11 40 CAD 2 HOCM IDCM 85 ARVC/D 35 Sarcoid Focal/Normal <0.5.mV AP UPHS database When to Consider ARVC Epi Voltage Map Epicardial Access • Substrate >1.0 mV – ARVC, DCM, Chagas, prior pericarditis • ECG – q waves inferior, V2, I, precordial “pattern break” • Imaging – MRI, ICE • Patient characteristics <0.5.mV – Age, comorbidities, prior CABG/valve surgery, pectus, hepatic enlargement 8
9/29/16 Site-specific Assessment of Epicardial VT Origin in DCM Surface ECG in VT Ø Fifteen patients with detailed endo/epi pacemapping and VT I Apical Superior Basal Superior LV Endocardium Apex Basal Inferior II Apical Inferior Bazan, Gerstenfeld … Marchlinski; Heart Rhythm 2007;4:1403-10 Site-specific Epi VT (Bazan) Criteria Epicardial VT In The Absence of Prior MI q wave I Basal Superior Apical Superior Best PM No q II, III, aVF VT1 q wave I Apex Basal Inferior LV Endo Q wave V2 QS II, III,aVF Apical Inferior Bazan, Gerstenfeld … Marchlinski; Heart Rhythm 2007;4:1403-10 9
9/29/16 When to Consider MRI Epicardial Access I II • Substrate III aVR – ARVC, DCM, HCM, Chagas, prior pericarditis aVL aVF • ECG V1 – Inferior q waves, precordial pattern break V2 V3 • Imaging V4 – MRI, ICE V5 V6 • Patient characteristics – Age, comorbidities, prior CABG/valve surgery, Ø 48 yo presenting with MMVT Ø Mid-wall delayed enhancement noted in the inferolateral pectus, hepatic enlargement wall at the base with extension to the subepicardial region. When to Consider Epicardial Intracardiac Echocardiogram Access • Substrate – ARVC, DCM, HCM, Chagas, prior pericarditis • ECG – Inferior q waves, precordial pattern break • Imaging – MRI, ICE, EAM • Patient characteristics – Age, comorbidities, prior CABG/valve surgery, pectus, hepatic enlargement 10
9/29/16 VT Surgery - Cryoablation Epicardial Puncture After Open-Chest Surgery LAA LCx and Plane of Mitral Valve Surgical Window Anter et al. Circulation EP 2011;1:494-500. Outcome After Ablation in NICM Limitations of Epicardial Ablation • Access – Risk of RV/LV perforation – Coronary vessel perforation – Liver/lung/bowel laceration – May not be accessible in prior CABG/valve surgery/ablation • Ablation – Fat, coronary vessels, phrenic nerve – Epicardial fluid accumulation – Catheter tip contact/orientation – Cardiac motion Tokuda M et al. Circ Arrhythm Electrophysiol. 2012;5:992-1000. 11
9/29/16 Epicardial HiFU Catheter New Technology for VT Ablation Ø 12 Fr OD nylon catheter housing A-mode HIFU Radiopaque imaging ablation orientation transducer transducer Ø HiFU ablation marker Ø Linear ablation Internal irrigation balloon Not available for human use Nazer B, et al. Circulation Arrhythmia EP , 2015. Representative Lesions HIFU Ablation Over LCX 1 mm 10 mm 250 μ m 10 mm Nazer B, et al. Circulation Arrhythmia EP , 2015. Nazer B, et al. Circulation Arrhythmia EP , 2015. 47 48 12
9/29/16 HIFU Mean Lesion Sizes Linear RF Catheter Ø 7 externally irrigated 3 mm RF ablation electrodes Ø 5 mm spacing Ø 25 W max power, titrated individually to each electrode RF 15W 20W 30W 5 mm nMARQ Not approved for human use Nazer B, et al. Circulation Arrhythmia EP , 2015. 49 50 Lesion Gaps Linear vs Focal Ablation Focal RF Linear RF Linear Focal B A 1 cm 1 cm Ø Gaps present in 53% focal lesions compared to 0% linear lesions Nazer B et al. Heart Rhythm, in press 51 52 13
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