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L’Ablazione delle aritmie ventricolari. Luigi Padeletti. Montecatini T.me, 14 Novembre 2007. Techniques for Ablation of VT. Original experience in catheter ablation of VT based on etablished criteria gained in - previous era of diagnostic electrophysiology

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slide1

L’Ablazione delle aritmie ventricolari

Luigi Padeletti

Montecatini T.me, 14 Novembre 2007

techniques for ablation of vt
Techniques for Ablation of VT
  • Original experience in catheter ablation of VT based on etablished criteria gained in

- previous era of diagnostic electrophysiology

- initial experience on RF ablation of regular

supraventirular tachycardias

Introduction

techniques for ablation of vt3
Techniques for Ablation of VT
  • Heterogeneity of substrates
  • Limits of lesion size produced by sources of energy delivered from the endocardium relative to the width and depths of the ventricular arrhythmogenic substrate

Methodological perspective

optimal substrate: focal source, subendocardial location!

techniques for ablation of vt4
Techniques for Ablation of VT

Classification

VT in the absence of apparent heart disease

VT in the presence of heart disease

  • post-infarction VT
  • non-infarction VT substrates
    • ARVD
    • dilated CMP
    • congenital HD
    • valvular HD
  • ILVT
  • RVOT
  • LVOT
  • Focal VT in other locations
  • VT originating from outside
  • the ventricles
techniques for ablation of vt5
Techniques for Ablation of VT

Criteria to discriminate the arrhythmogenic mechanism

Automaticity

Triggered activity

Reentrant

  • Eccentric propagation from
  • electrical source of earliest
  • activation
  • Intracardiac electrical
  • activation scanning
  • less than the tachy CL
  • Positive to entrainment
  • maneuvers
  • Intracardiac electrical
  • activation scanning the
  • entire tachy CL

relevant to localize the arrhythmogenic source!

techniques for ablation of vt6
Techniques for Ablation of VT
  • Techniques to enlarge lesion size (8-mm tip, cooled tip, irrigated cooled tip)
  • Techniques to display on accessible operational tools the 3-D anatomy of the VT substrate (Carto, En-Site, Loca-Liza…)

Developmental pathways

techniques for ablation of vt7
Techniques for Ablation of VT

Carto mapping

Methodological options

Advantages

  • Activation map
  • Propagation map
  • Voltage map
  • 3-D re-construction of
  • activation wave-front (VT, SR)
  • Identification of
    • scar tissue
    • areas w/ low voltage
    • areas w/ slow conduction

limit: sequential mapping required!

slide8

Post-Infarction VT

S

S

S

Cappato & Kuck, 2000

slide9

Mappaggio elettroanatomico

  • Consente la caratterizzazione delle
  • aree cicatriziali (scar) nel VD/VS
  • Mappaggio di aritmie sostenute e tollerate
  • Utilizzabile per effettuare ablazione lineare
  • della “scar”
  • Utilizzabile per il mappaggio del
  • versante endocardico o epicardico
techniques for ablation of vt10
Techniques for Ablation of VT

En-Site mapping

Methodological options

Practical fall-backs

- Propagation map

  • 3-D re-construction of
  • activation wave-front (VT, SR)
  • using a single beat
  • (ablation of unstable VT possible!)

limit: accuracy of 3-D re-construction and catheter navigation!

slide12

Mappaggio noncontact

  • Ricostruzione virtuale dell’ endocardio del
  • ventricolo destro/sinistro
  • Valutazione del pattern di attivazione dell’ endocardio
  • Individuazione di aree con attivazione tardiva o propagazione lenta
  • Analisi dell’ elettrogramma unipolare locale in RS
  • Analisi del pattern di attivazione (sito di uscita endocardico e
  • percorso diastolico) di camera durante:
  • -TV non sostenute o non tollerate
  • -TV polimorfe
  • -Molteplici morfologie di TV
rfca of vt in cmp and arvd
RFCA of VT in CMP and ARVD

Introduction

Histopathology of ablation

  • In pts dying early after RFCA of VT,
    • lesion size ranges from 2 - 5 mm to almost 2 cm bands (depending on number of RF applications)
    • Lesion depth ranges from 1 to 5 mm and deepens within partially scarred regions

relative inadequacy of energy source (RF) and approach

(endocardial) to the totality of potential target substrates!

rfca of vt in cmp and arvd14
RFCA of VT in CMP and ARVD

Introduction

Location of arrhythmic substrate

  • Endocardial
  • Intramural
  • Epicardial
rfca of vt in cmp and arvd15
RFCA of VT in CMP and ARVD

Introduction

Noninfarction VT substrates

  • Substantial differences
    • between different noninfarction substrates and post-infarction substrates
    • among different nonifarction substrates

EP similarity, when uniform morphology VT occurs!

rfca of vt in cmp and arvd16
RFCA of VT in CMP and ARVD

Electrophysiologic substrate

Characteristics in noninfarctionVT patients

  • Macroreentrant VT
    • endocardial diastolic activity in SR and during arrhythmia
  • Focal activity in up to 1 / 5th of pts with CMP
  • Specific locations for some noninfarction CMP of recognized mechanisms (ex., bundle branch reentrant VT in dilated CMP)

different ablation techniques and success rates!

rfca of vt in cmp and arvd17
RFCA of VT in CMP and ARVD

Electrophysiologic substrate

Characteristics in noninfarction VT patients

prevalence

success

Underlying mechanisms

  • Macroreentrant VT 62% 60%
  • Focal activity 27% 86%
  • BB reentrant VT 19% 100%

Delacretaz et al, 2000

rfca of vt in cmp and arvd18
RFCA of VT in CMP and ARVD

Bundle-branch reentrant VT

  • Tipically found in pts with dilated CMP
  • Usually with LBBB morphology, but RBBB also possible
  • Preliminary data suggest that in LBBB variant the viability of LA fascicle is essential for macro-reentry
rfca of vt in cmp and arvd21
RFCA of VT in CMP and ARVD

Bundle-branch reentrant VT

  • High success rate with RF applied to the endocardial sites recording the earliest RB potential
  • If LBBB VT, RF applied to the endocardial sites recording the earliest RB potential
rfca of vt in cmp and arvd22
RFCA of VT in CMP and ARVD

Bundle-branch reentrant VT

  • If LBBB present during SR, RF applied to the endocardial sites recording a LB potential (to prevent III degree AV block)
rfca of vt in cmp and arvd23
RFCA of VT in CMP and ARVD

Characterization of the substrate

  • In comparison to post-infarction VT,
    • focal activity (automaticity, triggered activity, micro-reentry) possibly limited to poorly accessible areas
    • possible absence of identifiable scar tissue
    • evolutional changes of underlying substrate
    • (new substrates may develop over time)
rfca of vt in cmp and arvd24
RFCA of VT in CMP and ARVD

Conclusions

  • Compared to regular SVT, RF ablation of VT associated with CMP and ARVD
    • less effective
    • is associated with higher rate of major complications
    • requires more complex mapping to match the variability and complexity of substrates
slide25

Ablation of postinfarction ventricular tachycardias

non inducible VT; unstable VT; VF

stable monomorphic VT

mapping during VT

substrate mapping in SR

mapping of triggering ectopies

reentry

focal

analysis of the reentry circuit and identification of critical SCZ

substrate ablation in SR

ablation of triggers

site of earliest activation

slide26

RFCA of PIVT based on VT mapping

Abl+

Abl-

Abl+/-

EF>30%

EF<30%

Della Bella et al. Eur Heart J 2002

slide27

Conventional RFCA for VT – An overview

Della Bella De Ponti Salerno

Eur Heart J

2002

124

73%

7.2%

19%

41.5 mos

21%

9.6%

2.4%

BorgerVanDerBurg - Schalij

JCE

2002

151

83%

7%

22%

34 mos

26%

7.2%

0.6%

O’Donnell Furniss

Eur Heart J

2002

112 (30un)

84-38%

6%

23%

61 mos

22%

11.6%

1.7%

Journal

Year

No. Pts.

Success

Complication

Use of ICD

FU duration

Recurrences

Non SCD

SCD-FU

slide28

Incessant vs paroxysmal VT

p

n.s.

n.s.

n.s.

<0.05

n.s.

n.s.

<0.01

n.s.

pVT

97

62±8

94%

29/60/11

1.9

407 ± 81

23%

16%

iVT

27

63±11

96%

25/40/35

1.7

412 ± 83

62%

22%

No. patients

Age (years ± SD)

Sex (M)

Site of MI (%a/i/m)

No. VT morphol.s/pt

Mean VT cl (ms)

Pts with EF < 30%

Pts with ICD

slide29

Incessant vs paroxysmal VT

p

0.63

0.35

0.41

0.82

0.73

iVT

78%

8±6

34±24’

188±51’

7.4%

pVT

72%

10±8

40±25’

191±53’

6.1%

Acute success

No. RF pulses

Fluoro time

Procedure dur.

Postablation ICD

slide30

Ablation of postinfarction ventricular tachycardias

non inducible VT; unstable VT; VF

stable monomorphic VT

mapping during VT

substrate mapping in SR

mapping of triggering ectopies

reentry

focal

analysis of the reentry circuit and identification of critical SCZ

substrate ablation in SR

ablation of triggers

site of earliest activation

slide31

Novel mechanism of PIVT originating in surviving left posterior Purkinje fibers

Bogun et al. JACC 2006

Hayashi et al. Heart Rhythm 2006

slide32

PIVT originating from surviving Purkinje fibers

Reithmann

JCE

Aug/07

8*

1

3

n.r.

430±49

8

3

-

Pur. Pot

7/8

0

Bogun

JACC

Dec/06

9

3

8

4.7±4.1 yrs

402±82

7

1

1

Pur. Pot

9/9

0

Hayashi

HR

Aug/06

4

2

2

4dys-17yrs

472±27

2

1

1

Pur. Pot

4/4

0

Journal

Year

No. Pts.

Prior MI

-ant

-inf

Time from MI

VT CL (ms)

VT morphology

-RBBBM+LS

-RBBBM+RS

-LBBBM

Abl. Target

Success

New cond. dist.

* Only 3 with prior myocardial infarction

slide33

Ablation of postinfarction ventricular tachycardias

non inducible VT; unstable VT; VF

stable monomorphic VT

mapping during VT

substrate mapping in SR

mapping of triggering ectopies

reentry

focal

analysis of the reentry circuit and identification of critical SCZ

substrate ablation in SR

ablation of triggers

site of earliest activation

slide34

Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy

Marchlinski et al. Circulation 2000

slide35

How long should be the line?

Defining electrically unexcitable scars

15.9 cm

Soejima et al. Circulation 2001

Soejima et al. Circulation 2002

79%

21%

slide36

Substrate mapping vs. tachycardia mapping using CARTO in patients with coronary artery disease and ventricular tachycardia: impact on outcome of catheter ablation

Volkmer et al. Europace 2006

slide37

Substrate mapping vs. tachycardia mapping using CARTO in patients with coronary artery disease and ventricular tachycardia: impact on outcome of catheter ablation

Volkmer et al. Europace 2006

slide38

Ablation of postinfarction ventricular tachycardias

non inducible VT; unstable VT; VF

stable monomorphic VT

mapping during VT

substrate mapping in SR

mapping of triggering ectopies

reentry

focal

analysis of the reentry circuit and identification of critical SCZ

substrate ablation in SR

ablation of triggers

site of earliest activation

slide40

Conclusive remarks

  • Ablation in combination with ICD is a valuable therapeutic option to treat ventricular tachycardias in patient with ischemic heart disease
  • The introduction of new technologies and the development of different approaches allow treatment of a wide range of arrhythmias encoutered in patients with ischemic heart disease
  • This results in improvement of the acute and mid-term outcome in these patients
  • Patients with incessant forms or electrical storms of fast ventricular arrhythmias are no longer lost cases, but can be successfully treated by ablation