Ventricular Tachycardia: Catheter Ablation/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc... ·...

Ventricular Tachycardia: Catheter Ablation

Who? How? When ? Results?

Vivek Y. Reddy, MD

Helmsley Trust Professor of Medicine

Director, Cardiac Arrhythmia Service

The Mount Sinai Hospital

[email protected]

Disclosures

• Grant support and/or Consultant:

– Abiomed Inc, Biosense-Webster Inc,

Stereotaxis Inc, St Jude Medical Inc

• I will be discussing off-label use of

catheter ablation devices.

Outline

• Scar-Related VT Ablation

• Outflow-Tract VT/PVCs

• Ventricular Fibrillation

Pathogenesis of Scar-Related VT

• Electrically-active live myocardial fibrils

traversing through the fibrotic tissue of the scar

EXCITABLE GAP

SCAR

EXCITABLE GAP

FUNCTIONAL BLOCK

SCAR

Post-MI VT: Catheter Ablation

• Post-MI VT is not a simple substrate with a single circuit

• Better to think of post-MI VT as an arrhythmogenic mass of tissue from which multiple VTs can emanate

• For clinical success need to treat not as circuits but as substrate Downar et al, JACC 1998

MV

1. Target Channels for Ablation

2. Target VT Exit Sites

Substrate Mapping & Ablation

ECG

Map

ECG

Map

1. Target Channels for Ablation

2. Target VT Exit Sites

Normal

Abnormal

3. Homogenize Scar

MV

Substrate Mapping & Ablation

Fre

edo

m f

rom

VT

The VISTA Trial

L.DiBiase et al, JACC 66:2872 (2015)

P < 0.001

Substrate Ablation of Unstable VTSingle & Multicenter Studies

• Marchlinski et al, Circulation 101:1288, 2000

• Soejima et al, Circulation 104:664, 2001

• Reddy et al, JACC 41:2228, 2003

• Kottkamp et al, JCE 13:675, 2003

Stevenson at al, Circulation 2009

Multicenter Thermocool VT Ablation IDE TrialLong-Term Outcomes

F.Marchlinski, C.Haffajee, J.Bashai et al, J Am Coll Cardiol 67:674 (2016)

VANISH: Post-MI VTRCT: AADs vs Catheter Ablation

JL.Sapp, GA.Wells, R.Prakash at al, NEJM 375:111 (2016)

Primary Prevention of ICD ShocksSMASH-VT

Preventative substrate ablation in preventing ICD shocks in post-MI pts who have sustained a VT/VF event (ie, 2°prevention ICD pts)

Follow-Up (2 years)

History of a MI

Cardiac Arrest

(VT/VF)

Randomization

ICD

ICD +

Substrate

Ablation

ICD Therapy

Fre

ed

om

fro

m IC

D R

x (

%)

Follow-Up (Months)

Ablation

Control

6 12 18 2400

20

40

60

80

10

0

(p = 0.003)

31.3 %

9.8 %

ICD Shocks

Reddy et al, NEJM, 357:2657 (2007)

ICD “Storm” Occurrence

• 6% vs 19%

• P = 0.06

Can catheter ablation reduce VT/VF

in post-MI patients undergoing ICD

implantation for stable VT?

Follow-Up (2 years)

History of a MI

Stable VT

LVEF < 50%

Randomization

ICD ICD +

Ablation

KH Kuck, et al, Lancet, 375:31-40 (2010)

Primary Prevention of ICD ShocksVTACH Study

Dinov B et al. Circulation 129:728-36 (2014)

Catheter Ablation in DCM-VTModerate Success (Compared to Post-MI VT)

VT-free Survival at 1 year:ICM = 57%, NICM = 40.5%

For DCM-VT, the only predictors of VT recurrence

were “Partial Success” or Failure.

Catheter Ablation in DCM-VTImproved Success with Scar Homogenization (?)

Göko�glan Y et al. J Am Coll Cardiol 68:1990-8 (2016)

The Difficult VT AblationCan we improve outcomes?

• Deep (Septal) Circuits

• Hemodynamic Support

• Bipolar RF

• EtOH Ablation

• Epicardial Ablation

• Neuraxial Modulation

Bogun at al, JACC 53:1138-45 (2009)

Mostly Intramural Scar:

What do you do?• Deep (Septal) Circuits


• Bipolar RF

• EtOH Ablation




Bipolar Ablation

Clinical Case Example

Sequential Unipolar Bipolar Ablation

J.Koruth / S.Dukkipati / M.Miller / P.Neuzil / V.Reddy Heart Rhythm (2012)

DCM-VT: Septal Scar




• Bipolar RF

• EtOH Ablation





• Bipolar RF

• EtOH Ablation






• Bipolar RF

• EtOH Ablation




Sternum

Liver

RV

LV

Modified from slide from: E Sosa, M Scanavacca, A d’Avila

ARVC-Related High Success of VT Ablation

• 17 Patients

• Mean f/u: 49 ± 21 mo

• Success rate: 88%

Epi/Endo Ablation

Reddy & Wilber, Manuscript in Preparation

RV EndocardiumVentricular Epicardium

TV

AP Burke, Medscape, http://emedicine.medscape.com

/article/1612324-overview



• Bipolar RF

• EtOH Ablation



Renal Denervation

Stellate Ganglionectomy


Renal Denervation

RSDN for Ventricular ArrhythmiasOn-Going Clinical Trials

RESCUE-VT

Follow-Up

ICD Therapy

2º Prevention

1º Prevention + Inducible VT

ICD Implantation

Placebo RSDN

R

Renal Angiogram



• Bipolar RF

• EtOH Ablation



Renal Denervation



Bourke et al, Circulation, 2010;121:2255.


Stellate Ganglionectomy Case SeriesICD Shocks: Left vs Bilateral CSD

Vaseghi et al, Heart Rhythm 11:360 (2014)

Success & Mortality After VT AblationEffect of Acute Inducibility: Mortality

P.Della Bella at al, Circulation 127:1359 (2013)

• 528 scar-VT patients treated with ablation

• Results of programmed stimulation:–Class A (Non-inducibility of any VT) 77%

–Class B (Inducibility of “non-clinical” VT) 12.4%

–Class C (Inducibility of “clinical” VT) 10.6%

Transplant/Mortality After VT AblationOutcome as a Function of Ablation Success

Transplant-Free Survival

Predictors of Transplant/Mortality

R.Tung, M.Vaseghi, DS.Frankel at al, Heart Rhythm 6:351 (2013)

Transplant/Mortality After VT AblationOutcome: Relationship to Functional Class

R.Tung, M.Vaseghi, DS.Frankel at al, Heart Rhythm 6:351 (2013)

Outline




Outflow-Tract VT

• Structurally-normal heart

• RVOT- or LVOT-VT

• ECG:

– Typically LBBB (or RBBB)

– Positive QRS in II / III / aVF

– QRS transition V3/V4

• Early transition LVOT

• Can be RBBB

• Not life-threatening

– [rare exceptions]

45 yo Fireman with OTVT ICDICD Interrogation

RVOT VT Ablation

RF on

Map

SBP

EC

G

What about PVCs?

Canine ModelBigeminal PVC Pacing vs Control

Huizar JF, et al. Circ Arry 2011;4:543-9.

Penela et al, JACC, 62:1195 (2013)

• 13% baseline PVC burden: 100% Sens / 85% Specificity to predict an absolute LVEF increase of 5% after catheter ablation

• 20 patients with Class I ICD indication no longer eligible at 6 months post-ablation.

Effect of PVC Ablation Prospective 4-Center Study (n=80 pts)

Lakkireddy et al, JACC 60:1531 (2012)

• 65 CRT Non-Responders with >10,000 PVCs/24h undergoing ablation• Age 66.6, 78% male, QRS duration = 155±18 msec• Acute and 12-mo success of ablation: 91% and 88%• Improvements in LVEF (26.2 32.7%, p 0.001)

– LVESD, LVEDD, LVESV, LVEDV, NYHA (3.0 to 2.0, p 0.001)

CRT Non-Responders Effect of PVC Ablation

Olgun et al, Heart Rhythm 8:1046 (2011)

Yokokawa et al, Heart Rhythm 9:92 (2012)

Yokokawa et al, Heart Rhythm 9:1460 (2012)

Predictors of PVC-CardiomyopathyInterpolated PVCs

• Interpolated PVCs– Higher risk for Cardiomyopathy

• Symptoms– Asymptomatic: HR = 13– Long duration (>60mo): HR=20

• QRS Width– QRS >150ms best predictive– Sens = 80% / Spec = 52%

Outline




– Focal Trigger Ablation

– Substrate Modification (Brugada)

Case: 16 yo, Normal LVEF, Syncope Exercise Treadmill Testing

ICD + BBL Shocks while riding a bicycle

Ventricular FibrillationFocal Triggers

Haissaguerre M, et al, Lancet (2012)

RVOT muscle

16%

Both foci in 4 pts

Purkinje 84%

LV dist

LV prox

Initiation of VF by “Purkinje beats”

Courtesy: Michel Haissaguerre

Case: Ablation

VF Triggers in Other Disease StatesChannelopathy & Post-MI

LQTS

Brugada

Brugada

Haissaguerre et al, Circ 108:925 (2003)

Bansch et al, Circ 108:3011 (2003)

VF Substrate Mapping in Brugada SyndromeNormal and Abnormal Epicardial Electrograms

K.Nademanee et al, Circulation 123:1270 (2011)

VF Substrate Mapping in Brugada SyndromeEffect of IV Flecainide

J.Brugada, C.Pappone, A.Berruezo et al, Circ Arry 8:1373 (2015)

Post-FlecainidePre-Flecainide

Brugada Syndrome: VF Substrate Ablation ECG Pattern During Follow-Up

J.Brugada, C.Pappone, A.Berruezo et al, Circ Arry 8:1373 (2015)

Baseline

Post-Flecainide

Pre-Ablation Follow-Up

Final Thoughts

• Scar-Related VT:– Ablation is safe!

– Ablation success is moderate in DCM

– ARVC-VT Ablation: Excellent Outcome

• Outflow-Tract VT

– Recognize it! ICDs are not indicated

– PVCs – When to intervene?

• Symptoms

• Ventricular Dysfunction / Dilatation

• High burden??


– PVC Triggers

– Brugada Syndrome: Substrate Ablation

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