Role of non-invasive imaging in transcatheter ablation of … Card/Paediatric II/Sabrina... ·...
Transcript of Role of non-invasive imaging in transcatheter ablation of … Card/Paediatric II/Sabrina... ·...
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Role of non-invasive imaging
in transcatheter ablation of arrhythmias in CHD
Sabrina Tsao, MBBS MRCP(UK) FACC
Associate Professor
Paediatric Cardiology
University of Hong Kong
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No conflicts of interests to disclose
Sabrina Tsao, MBBS
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Outline • Understand the unique issues in patients with CHD
• Understand the cause and impact of arrhythmias in
CHD patients
• Understand the evolution of technology in
electrophysiology
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Anatomy in CHD patients • Variable anatomy:
o Heterotaxy syndromes (atrial isomerisms)
o Atrio-ventricular and/or ventriculo-arterial discordance
o Ventricular anatomy: 2 ventricles, single ventricle
Variants of single ventricle
o Abnormal AV node position; twin AV nodes
o Accessory connections
AV valve atresia: Tricuspid atresia, single LV
Mitral atresia, single RV
Aortic atresia:
HLHS Double inlet left ventricle
Heterotaxy syndrome
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Arrhythmias in CHD • Consequence of corrective surgery:
o SAN/ AVN injury
o Fibrosis: Surgical incisions and patch
material
o Regions of slow conduction within
existing anatomical isthmuses
• chronic cyanosis
• pressure +/- volume overload
• ageing
• pathological hypertrophy
Bouchardy J et al Circ 2009
Brouwer C et al Arrhythm Electrophysiol Rev 2016
Khairy P et al. Heart Rhythm 2014
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Arrhythmias in (A)CHD • Many CHD patients eventually develop arrhythmias
• Morbidity & Mortality: o 50% increase in mortality
o 2x risk of stroke/ CHF
o 3x risk of cardiac interventions
• Catheter ablation has relatively good acute
success rates, reaching 60-80% even in single
ventricle patients
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Ablation in (A)CHD • Plan ablation procedure:
o Review operative reports
o Vascular access, access to pulmonary venous atrium
o Location of AV node
o Obtain CT/MRI in pts with complex anatomy pre-procedure
o Activation and voltage mapping
• use of 3D contact and non-contact mapping systems
• MRI/ CT image integration
o Catheters: irrigated tip, contact force, cryoablation
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From past to future in EP
Fluoroscopy
Electroanatomic mapping
CT/MRI integration
ICE
Future technologies
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Electrophysiology procedures • Catheters are traditionally placed under fluoroscopy:
RAO LAO
• Allows electrophysiologists to “view” the heart in 2
orthogonal planes, hence in “3D”
His = AVN CS = coronary sinus RVa = RV catheter t/s = transseptal sheath
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4yo with HLHS (MA/AA) • S/p Norwood procedure with DKS and BT shunt,
s/p bilateral bidirectional Glenn
• WPW syndrome with frequent SVT in newborn
period, with occasional recurrence
• Sinus bradycardia limited dose of beta-blocker
• Wt. 15 kg
• LFV thrombosis noted at pre-Fontan cath/EP
study
• Access: o RIJ, RFV, RFA
o Transesophageal pacing catheter
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XR • Bidirecitonal
Glenn, so SVC connects to the
PAs
With only RFV access:
• His-RV catheter
to obtain AVN
recording and pace/ record
RV
• TEP to record
and pace LA
His
RV TEP
His
RV TEP
RAO and LAO of HIS position
RAO and LAO of ablation site
TEP TEP ABL
ABL
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Using electroanatomic mapping
• Mark location of
AVN and TV
• Fluoro time:
<3 mins
• Successful ablation
with the 1st lesion
RAO
AVN
RV
TEP
Aorta
Aorta
TVA
5-Fr ablation catheter at
successful site, 6:00 MVA
LAO
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Loss of AC in RF#1
AV fusion AV separation
I
II
aVF
V1
V6
ABLp
ABLd
RVd
TEP
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36yo with single ventricle • Double inlet RV, hypoplastic LV, VSD, VA
discordance, s/p atriopulmonary Fontan
• Recurrent atrial tachycardia despite medications
• Preserved hemodynamics
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Pre-procedure CT • Initial mapping
with Orion
basket missed
the pouch
• After CT fusion,
the missing
pouch was
mapped
• Earliest activation was
in the pouch
Courtesy of HF Tse/ SY Kwok, QMH
Earliest
EAM CT
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Termination of AT
Courtesy of HF Tse/ SY Kwok, QMH
Termination Point
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Intracardiac ECHO (ICE) • To aid transseptal puncture:
o use of XR, safety
o BUT – may not be feasible in smaller
children
• To improve catheter contact
in big chambers
Sherwin EA et al CircAE 2013
Mustard patient A. Anatomic shell based on
echo images with neo-LA
details
B. Direct visualization of
ablation catheter tip
during RF verifying tissue
contact
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Future advances • ECVue
• Personalized virtual-heart technology
• Real-time MRI guided mapping
• Optogenetics
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ECVue – in AF • CardioInsight vest contains 252
electrodes
• Perform cardiac CT or MRI
• Combine them to map spatiotemporal
electrical patterns during AF o high resolution
o patient specific
o 3D biatrial geometry
• AFACART study: o 118 persistent AF pts in 8 European centers
o ECVue driver-only ablation -> 64% AF termination
o With additional ablation -> 72% total AF termination rate
o At 1-year FU, 78% pts off AADs and 88% free from AF
recurrence
Konrad T et al. Herzschr Elektrophys 2014
Knecht S et al. Europace 2017
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Future advances • ECVue
• Personalized virtual-heart technology
• Real-time MRI guided mapping
• Optogenetics
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Virtual heart technology
• Use LGE-MRI images to create
an individualized geometric
virtual model of ventricles
• Perform virtual multi-site
ventricular pacing to induce VT
• Use VAAT to predict minimum-
sized “optimal” ablation lesions.
Repeat VT stimulation protocol
• Incorporate into EAM
Prakosa A et al, Nat Biomed Eng 2018
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Future advances • ECVue
• Personalized virtual-heart technology
• Real-time MRI guided mapping
• Optogenetics
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Real-time MRI guided EP
Mukherjee RK et al. Curr Cardiovasc Imaging Rep 2019
Pros
Real-time 3D substrate assessment
Accurate intra-procedural guidance in combination with EAM system
Evaluation of ablation effectiveness: - Acute tissue edema with T2 imaging - Assess lesion necrosis with LGE - MR thermometry
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Real-time MRI guided EP Cons
Large lab space
Availability and range of MR-compatible devices
MR scan creates electromagnetic fields that can interfere with intracardiac EGMs, so need filtering system, computer processing
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Future advances • ECVue
• Personalized virtual-heart technology
• Real-time MRI guided mapping
• Optogenetics
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Optogenetics • Use transgenic mice with light-sensitive
channel channelrhodopsin-2 (ChR2)
expressed in cardiac tissue o Blue light can optically pace the heart in vivo
o Red light can perform optical defibrillation
• Optical mapping o Mapping the entire surface of the heart
Bruegmann T et al J Clin Invest 2016
Boyle PM et al JACEP 2018
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Thank you!
EP
Cardiac radiologists Engineers
IT