Epicardial Technology and multidisciplinary approach for...
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Epicardial Technology and multidisciplinary approach for
Ventricular Arrhythmias:present and future
Paolo Della BellaOttavio Alfieri
Elisabetta La PennaArrhythmia Unit and EP Laboratories- Cardiac Surgery
San Raffaele Hospital Milan, Italy
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• Surgical access– Unfeasible access to the LV
– Epicardial adhesions
– Previous cardiac surgery
• Epicardial mapping/ablation– Need for extensive epicardial ablation (Cryoprobe)
– Need to displace the course of coronary artery/phrenicnerve
– Indication to concomitant cardiac surgery
Surgical VT ablation- Rationale
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Surgical VT ablation- Indications from current Guidelines
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1204 Ablation procedures in 958 patients(2010-2017)
VT etiologies
45%
26%
9%
8%5%
1% 6%Underlying heart disease
CAD IDCM ARVD Myocarditis Valvular Congenital Other non ischemic
Ventricular Tachycardia ablation in the setting of SHD- OSR experience
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Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017
Surgical access-ablation in 43/958 patients (4,4%)
IHD40%
IDCM26%
Myocarditis14%
Valvular16%
Congenital2%
HCM2%
VT etiologies
Clinical Characteristics Pts, N (%)
Age, ys, Mean±SD 63±11
EF, %, Mean±SD 34±13
Male 42 (97,6%)
NYHA Class I-II 28 (65,1%)
NYHA Class III-IV 15 (34,9%)
Paroxysmal VT 27 (62,8%)
Incessant VT 2(4,6%)
Electrical Storm 14(32,6%)
ICD 41 (95,3%)
Failed AADs 40 (93.1%)
Failed Ablation 26 (60,4%)
Previous Surgery 16 (37,6%)
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Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017
43 patients
Surgical access
Indications to surgical approach/ablation:
Previous cardiac surgery: 13/43 pts (30,2%)Double prosthetic valve: 3/43 pts (7%)Failed percutaneous epi access: 8/43 pts (18,6%)Apical thrombus: 8/43 pts (18,6%)Deep substrates: 6/43 pts (14%)Indication to aneurismectomy: 2/43 pts (4,6%)Indication to cardiac surgery: 1 pt (2,4%)Previous epi ablation limited by CA/PN: 2/43 pts (4,6%)
In-procedure switch to epicardial surgical approach in 3 pts (failed endo ablation)
Thoracotomy Sternotomy Transapical Marfan
18
10
3
12
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Male, 41 yo
2 previous failed epicardial ablation attempts (other Country)
Recurrent VTs treated by ATP/shocks
Previous single chamber ICD implant
Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017
Clinical case
Chest CT scan: posterior slice Chest CT scan: anterior slice
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Multidisciplinary approach for VAs: the OSR experienceClinical Case
Procedure Data-1
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Multidisciplinary approach for VAs: the OSR experienceClinical case
Procedure data
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Multidisciplinary approach for VAs: the OSR experienceClinical Case
Procedure data-Epicardial Mapping
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Multidisciplinary approach for VAs: the OSR experienceClinical Case
Procedure data- Endocardial mapping
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Multidisciplinary approach for VAs: the OSR experienceClinical case
Procedure Data-Ablation Endpoint
Remap
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Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017
51%
19%
30%
Endo Endo-epi Epi
77%
14%
7%
2%
No support ECMO IABP VAD
Ablation approach Haemodynamic support
16%
84%
Cryo RF
Ablation source
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12%
70%
16%
2%
EPS not done Class A Class B Class C
FU 45+24 months:
VT recurrence: 14 (32%)AHF: 12 (27,9%)
Redo percutaneous procedure: 2 pts (4,6%)
Acute procedure success
Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017
In Hospital Outcome
VT recurrence 5/43 (11,6%)
ES recurrence 2/43 (4,6%)
Complications:
Pericardial effusion 1 (2,3%)
Pleural effusion 1 (2,3%)
Infection of the surgical access 2 (4,6%)
Death (cardiogenic shock) 1 (2,3%)
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• Although the indication to surgical access/ablation for treatment of VAs is limited, the cooperation betweenelectrophisiologists and surgeons is the key to success in verydifferent complex settings.
• Long-term success and acute complication rates are quiteacceptable in this high-risk population.
Conclusions