Management of Ventricular Arrhythmias in NICM: Catheter Ablation

14 Pages·2012·3.67 MB·English

9/8/2012
Management of VT in Non-ischemic Acknowledgements
Cardiomyopathy: Catheter Ablation and
• NIH
Beyond • NIH-Bioengineering Research Partnership
• American Heart Association
Kalyanam Shivkumar, MD PhD FACC
UCLA Cardiac Arrhythmia Center & EP Programs • DISCLOSURES:
UCLA Health System
• University of California (UCLA) Holds Patents
in This Area: catheter technology, embolism
prevention technology, minimally invasive
methods for cardiac interventions
BERKELEY • DAVIS • IRVINE • LOS ANGELES • RIVERSIDE • SAN DIEGO • SAN FRANCISCO SANTA BARBARA • SANTA CRUZ
Willem Einthoven (Semarang, May 21, 1860 –Leiden, September 29, 1927)
Management of VT in
Non-ischemic Cardiomyopathy
• Clinical Approach
• Pathophysiology
• Catheter Ablation
• Beyond Catheter Ablation
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Multiple VT’s with basal exits
VTSO regions.MI
Hutchinson MD, Marchlinski FE: Epicardial Ablation of VT in patients with non ischemic LV cardiomyopathy:
Adapted from: John Miller, MD , Univ of Indiana Cardiac Electrophysiology Clinics, 2(1);93-103. 2010
Management of VT in Non-
Causes of VT in NICM
ischemic Cardiomyopathy
• Scar based macroreentry
• Clinical Approach
• BBR
• ‘Functional’ VT’s
• Pathophysiology
• Catheter Ablation
• Beyond Catheter Ablation
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FROM SCAR TO VENTRICULAR ARRHYTHMIAS
ARRHYTHMIAS
Leenen FHH: Circ Res 2007;101:221-223
REPONSE TO CARDIAC INJURY INVOLVES NEURAL REMODELING BEYOND THE HEART
Neural
Remodeling
Myocardial
Level
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Courtesy: Peng-Sheng Chen MD and Michael Fishbein MD inA mHeurmicaann Cs owlleitghe Cofa Crdaridoimolyogoyp,a Vtohluym . eC i5r9c,u Islasuteio 1n0 ,A 6r rMhayrtchhm 2i0a1s2 ,& P aEgleesc t9r6o2p-9h6y4siology 2012 (in press).
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Knowledge about VT Circuits: Limits of our
Management of VT in
Extrapolation of Knowledge from Post-MI
Non-ischemic Cardiomyopathy
• MMVT Circuits Are Deep Within Scar: ICM >NICM
• Clinical Approach • Scar Border Zones Are Critical: NICM ±
• Late potentials an ‘electrical footprint’: ICM>NICM
• Pathophysiology
• Clinical Imaging Is Providing New Insights
• Mapping Techniques Have Greatly Improved
• Catheter Ablation
• Epicardial vs Endocardial Scar: NICM>ICM
• Beyond Catheter Ablation • Interplay Between Structural VT And Functional
Components: NICM possibly> ICM
Voltage map:non-ischemic cardiomyopathy
Hsia HH, Callans DJ, Marchlinski FE. Characterization of endocardial electrophysiological substrate in patients with Hsia HH, Callans DJ, Marchlinski FE. Characterization of endocardial electrophysiological substrate in patients with
nonischemic cardiomyopathy and monomorphic ventricular tachycardia. Circulation. 2003;108(6):704-710. nonischemic cardiomyopathy and monomorphic ventricular tachycardia. Circulation. 2003;108(6):704-710.
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Epicardial Map: Non-Ischemic Cardiomyopathy
Voltage Map-Anatomical Correlation: NICM
Epi
*
His End
RA ICE o
RV
*
FLUOROSCOPY
ECG
L I
Normal
Abl d
Border 1 mV
Abl d
EPICARDIAL VOLTAGE
MAP Scar
Cesario D, Vaseghi M, Boyle NG, Fishbein MC, Valderrabano M, Narasimhan C, Wiener I and Shivkumar K. Value of High TARGETED VT Abl d
density Epicardial and Endocardial Mapping for Catheter Ablation of Hemodynamically Unstable Ventricular Tachycardia. ELECTROGRAMS
Heart Rhythm2006 ;3:1-10 Cesario D, Vaseghi M, Boyle NG, Fishbein MC, Valderrabano M, Narasimhan C, Wiener I and Shivkumar K. Value of High
density Epicardial and Endocardial Mapping for Catheter Ablation of Hemodynamically Unstable Ventricular Tachycardia.
Heart Rhythm2006 ;3:1-10
Non-Ischemic Cardiomyopathy: Epicardial ‘Scar’
Peri-Annular
His Endo Scar
Epi
RV
Epicardial
Voltage Map
Cesario D, Vaseghi M, Boyle NG, Fishbein MC, Valderrabano M, Narasimhan C, Wiener I and Shivkumar K. Value of
High density Epicardial and Endocardial Mapping for Catheter Ablation of Hemodynamically Unstable Ventricular
Tachycardia. Heart Rhythm2006 ;3:1-10 Hutchinson MD, Marchlinski FE: Epicardial Ablation of VT in patients with non ischemic LV cardiomyopathy:
Cardiac Electrophysiology Clinics, 2(1);93-103. 2010
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Examples Of Late Potentials: Moderate (mLP) and Very Late (vLP)
. J Am Coll Cardiol2010;55(21):2355-2365
Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K.
Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation
of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol2010;55(21):2355-2365
Endocardial (ENDO) and epicardial (EPI) electroanatomical LV voltage maps
from a representative patient with nonischemic cardiomyopathy (NICM)
Differences In Scar Area And Late Potentials Between NICM And ICM
P<0.0001
P=0.012
P=0.0017
Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K. Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K.
Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation
of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol2010;55(21):2355-2365 of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol2010;55(21):2355-2365
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Substrate Differences Between ICM and NICM
Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K.
Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation Cano O, Hutchinson M, Lin D, Garcia F, Zado E, Bala R, Riley M, Cooper J, Dixit S, Gerstenfeld E, Callans D,
of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol2010;55(21):2355-2365 Marchlinski FE. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular
tachycardia in left ventricular nonischemic cardiomyopathy. J Am Coll Cardiol. 2009;54(9):799-808.
Isolated Septal Substrate for NICM
Haqqani, H.M., Tschabrunn, C.M., Tzou, W.S., Dixit, S.,Cooper, J.M., Riley, M.P., Lin, D., Hutchinson, M.D., Garcia, F.C., Bala,R.,
Kuhne M, Abrams G, Sarrazin JF, Crawford T, Good E, Chugh A, Ebinger M, Jongnarangsin K, Pelosi F, Jr., Oral H, Morady F, Verdino,R.J., Callans, D.J., Gerstenfeld, E.P., Zado, E.S., Marchlinski, F.E., Isolated Septal Substrate for Ventricular Tachycardia in
Bogun FM. Isolated potentials and pace-mapping as guides for ablation of ventricular tachycardia in various types of Nonischemic Dilated Cardiomyopathy: Incidence, Characterization and Implications,Heart Rhythm (2011), doi:
nonischemic cardiomyopathy. J Cardiovasc Electrophysiol. 2010;21(9):1017-1023. 10.1016/j.hrthm.2011.03.008.
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INTRA-SEPTAL VT : MAPPING AND ABLATION INTRA-SEPTAL VT : MAPPING AND ABLATION
S1 S2
Tholakanahalli V, Bertog S, Roukoz H & Shivkumar K: Catheter Ablation Of
Ventricular Tachycardia Using Intracoronary Wire Mapping And Coil
Embolization: Description Of A New Technique. 2012 (in revision)
TholakanahalliV, BertogS, RoukozH & Shivkumar K: Catheter Ablation Of Ventricular Tachycardia Using Intracoronary Wire
Mapping And Coil Embolization: Description Of A New Technique. 2012 (in revision)
RVOT Septal Perforator 1 Septal Perforator 2 Epicardial VT Originating from LV base in a patient with a VAD
MathuriaNS, Vaseghi M, Buch E, Shivkumar K. Successful ablation of an epicardial ventricular
Tholakanahalli V, Bertog S, Roukoz H & Shivkumar K: Catheter Ablation Of Ventricular tachycardia using a surgical ablation tool. CircArrhythmElectrophysiol. 2011;4:e84-86
Tachycardia Using Intracoronary Wire Mapping And Coil Embolization: Description Of A
New Technique. 2012 (in revision)
UCLA Cardiac Arrhythmia Center
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Surgical Access to LV base via lateral thoracotomy and Post-ablation Images of Epicardial Aspect of LV
Epicardial ablation with closed irrigated catheter and surgical
ablation pen
Surgical Ablation Pen
LMCA
Closed Irrigated Catheter Closed Irrigated Catheter
Surgical Ablation Pen His
His
CS
VAD cannula
CS
VAD cannula
MathuriaNS, Vaseghi M, Buch E, Shivkumar K. Successful ablation of an epicardial ventricular
tachycardia using a surgical ablation tool. CircArrhythmElectrophysiol. 2011;4:e84-86
MathuriaNS, Vaseghi M, Buch E, Shivkumar K. Successful ablation of an epicardial ventricular
tachycardia using a surgical ablation tool. CircArrhythmElectrophysiol. 2011;4:e84-86
UCLA Cardiac Arrhythmia Center Bipolar Linear Ablation Pen Isolator™ Atricure Inc, Cinncinnati OH UCLA Cardiac Arrhythmia Center
Management of VT in Non- Knowledge about VT Circuits: ICM vs NICM
ischemic Cardiomyopathy
• MMVT Circuits Are Deep Within Scar: ICM >NICM
• Clinical Approach • Scar Border Zones Are Critical: NICM ±
• Late potentials an ‘electrical footprint’: ICM>NICM
• Pathophysiology
• Clinical Imaging Is Providing New Insights
• Mapping Techniques Have Greatly Improved
• Catheter Ablation
• Epicardial vs Endocardial Scar: NICM>ICM
• Beyond Catheter Ablation • Interplay Between Structural VT And Functional
Components: NICM possibly> ICM
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The Autonomic Nervous System
regulates all cardiac physiological
functions
• Chronotropy (depolarization, repolarization)
• Dromotropy
• Inotropy
• Lusitropy
Sympathetic Modulation is Central to
Pathogenesis of Arrhythmias Due to Structural
and Functional VT’s (reentrant and non-
reentrant…e.g. LQTS, CPVT)
Paolo Mascagni (1752-1815)Anatomia Universa:
CARDIAC SYMPATHETIC CONTROL SYMPATHETIC MODULATION TO TREAT VENTRICULAR ARRHYTHMIAS
Vaseghi M, Ajijola A, Mahajan A, and Shivkumar K: Sympathetic Innervation, Denervation and Cardiac
Arrhythmias ‘Cardiac Electrophysiology: From Cell to Bedside’Zipes, D & Jalife, J, 6th ed. Elsevier, 2012 Vaseghi M, Ajijola A, Mahajan A, and Shivkumar K: Sympathetic Innervation, Denervation and Cardiac
Arrhythmias ‘Cardiac Electrophysiology: From Cell to Bedside’Zipes, D & Jalife, J, 6th ed. Elsevier, 2012
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