2 9 16 Epicardial Mapping And Ablation Techniques To Control Ventricular Tachycardia Syllabus
2016-02-09
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O RNIA, LO S ANG ELES GELES • RIVERSIDE • SAN DIEGO • SAN FRANCISCO 2/8/2016 HOW TO DECIDE ON AN INITIAL APPROACH: ENDO, EPI, OR BOTH? Noel G. Boyle MD PhD, Jason Bradfield MD, Kalyanam Shivkumar, MD PhD UCLA SANTA BARBARA • SANTA CRUZ Cardiac Arrhythmia Center Interventional Cardiovascular Programs Neurocardiology Research Center of Excellence Cardiac Arrhythmia Center The mission of the UCLA Cardiac Arrhythmia Center is to generate new knowledge in the field of cardiac electrophysiology and cardiovascular therapeutics DISCLOSURES: University of California (UCLA campus) has patents developed by my group in the areas of catheter technology, embolism prevention technology, minimally invasive methods for cardiac interventions, cardiac neural diagnostics and therapeutics 1 2/8/2016 When to go epicardial • General concepts • ECG criteria • Etiology & Imaging criteria SCHEMATIC OF PERICARDIAL SINUSES AND ACCESS TO VARIOUS EPICARDIAL REGIONS VIA THE PERICARDIAL SPACE Sheath in in front Transverse Sheath of Sinus Great Arteries A RCA HRA HIS ENDO SVC RV CS Anterior Access: EPI Lateral Tricuspid annulus Aorta B Halo Anterior Right Ventricle PA Aorta PA RSPV LAA LSPV LIPV RIPV Inferior/Posterior/Lateral Access areas Lateral mitral annulus LAA LV ant and lat wall Posterior left atrium (via oblique sinus) Diaphragmatic surfaces of RV and LV C Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology Circulation 2012 ;126:1752-1769 EPICARDIAL ACCESS NEEDLES AND LANDMARKS FOR NEEDLE ENTRY RV Curved end faces Heart Liver Direction of Needle Entry Open end away from Heart toward right inferior quadrant 3-6 O'clock viewed from caudal view Inferior Anterior Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology 2012 Circulation 2012 ;126:1752-1769 2 2/8/2016 Dangers of Pericardial Access • • • • • RV perforation Pericardial bleeding Liver Injury Abdominal Bleeding Entry into left pleural space epicardial/intramural hematoma RV perforation Liver entry ELECTROANATOMIC MAPPING AIDED EPICARDIAL ACCESS Bradfield J, Tung R, Vaseghi M, Moriarty JM, Boyle NG, Buch E, Mandapati R, Shivkumar K. Our Approach To Minimize Risk Of Epicardial Access: Standard Techniques With The Addition Of Electroanatomic Mapping Guidance. Journal of Cardiovascular Electrophysiology 2013 (in press) Approach to Assessing Need for Epicardial Access/Ablation 1. ECG suggest Epicardial VT exit site A B YES NO Consider obtaining 2. Prior unsuccessful Endocardial Ablation Epicardial YES NO Access for 3. Define SCAR location with CE imaging: Sub epicardial or mid-myocardial scar Mapping YES (and NO 4. Consider likelihood of Epicardial circuit for Underlying Substrate: Ablation) C HIGH LOW Perform Endocardial Mapping and Ablation first A ECG Criteria (Berruezo et al Circ 2004) 1) Pseudo-delta >34 ms B ECG Criteria for NICM (Valles E Circ AE 2010) 1) Absence of inferior Q wave C Probability of Epicardial Focus (Sacher F et al JACC 2010) Normal 6% 2) IDT (V2) >85 ms 2) Pseudodelta ≥75 ms ICM 16% 3) Shortest RS complex >121 ms 3) MDI >0.59 NICM 35% ARVC 41% Other CM 18% 4) Presence of Q wave in lead I 4) ORS duration >211 ms Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology, Circulation 2012;126:1752-1769 3 2/8/2016 When to go epicardial • General concepts • ECG criteria • Etiology & Imaging criteria ECG CRITERIA FOR NON ISCHEMIC CARDIOMYOPATHY 1) Absence of inferior Q wave 2) pseudo-delta ≥75 ms 3) MDI >0.59 4) Presence of Q wave in lead I Valles E, Bazan V, Marchlinski FE. Ecg criteria to identify epicardial ventricular tachycardia in nonischemic cardiomyopathy. Circ Arrhythm Electrophysiol. 2010;3:63-71 4 2/8/2016 TWELVE-LEAD ECG FEATURES TO IDENTIFY VENTRICULAR TACHYCARDIA ARISING FROM THE EPICARDIAL RIGHT VENTRICLE 1) pseudo-delta >34 ms 2) intrinsicoid deflection time (v2) >85 ms 3) shortest RS complex >121 ms 4) QRS duration >211 ms Bazan V, Bala R, Garcia FC, Sussman JS, Gerstenfeld EP, Dixit S, Callans DJ, Zado E, Marchlinski FE. Twelve-lead ECG features to identify ventricular tachycardia arisingfrom the epicardial right ventricle. Heart Rhythm. 2006;3:1132-1139 QRS CHARACTERISTICS FAIL TO RELIABLY IDENTIFY VENTRICULAR TACHYCARDIAS THAT REQUIRE EPICARDIAL ABLATION IN ISCHEMIC HEART DISEASE •Pseudodelta wave (PdW) •Intrinsicoid deflection time (IDT) •Shortest RS complex (SRS) •QRS duration (QRSd) •Maximum deflection index (MDI) •Q or q wave in lead I (QWL1) •Absence of q waves in inferior leads aVR/aVL ratio Martinek M, Stevenson WG, Inada K, Tokuda M, Tedrow UB. QRS characteristics fail to reliably identify ventricular tachycardias that require epicardial ablation in ischemic heart disease. J Cardiovasc Electrophysiol. 2012;23:188-193 ECGI: Surface ECG combined with CT imaging to produce 3D maps of electrical activity on the surface of the human heart. Shivkumar K , Narayan SM Science Transl Med 2011;3:98fs2-98fs2 5 2/8/2016 ECGI ISOCHRONE MAPS FOR LOCALIZATION OF VT SITE OF ORIGIN Wang Y, Cuculich PS, Zhang J, Desouza KA, Vijayakumar R, Chen J, Faddis MN, Lindsay BD, Smith TW, Rudy Y. Noninvasive Electroanatomic Mapping of Human Ventricular Arrhythmias with Electrocardiographic Imaging. Science Translational Medicine. 2011 3(98):98ra84. When to go epicardial • General concepts • ECG criteria • Etiology & Imaging criteria Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, Hocini M, Koplan B, Leroux L, Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG. Epicardial ventricular tachycardia ablation a multicenter safety study. J Am Coll Cardiol. 2010;55:2366-2372 6 2/8/2016 SUMMARY: EPI, ENDO or BOTH 1. ECG suggest Epicardial VT exit site B A YES NO Consider obtaining 2. Prior unsuccessful Endocardial Ablation Epicardial YES NO Access for 3. Define SCAR location with CE imaging: Sub epicardial or mid-myocardial scar Mapping YES (and NO 4. Consider likelihood of Epicardial circuit for Underlying Substrate: Ablation) C HIGH LOW Perform Endocardial Mapping and Ablation first C B A ECG Criteria (Berruezo et al Circ 2004) 1) Pseudo-delta >34 ms ECG Criteria for NICM (Valles E Circ AE 2010) 1) Absence of inferior Q wave Probability of Epicardial Focus (Sacher F et al JACC 2010) Normal 6% 2) IDT (V2) >85 ms 2) Pseudodelta ≥75 ms ICM 16% 3) Shortest RS complex >121 ms 3) MDI >0.59 NICM 35% ARVC 41% Other CM 18% 4) Presence of Q wave in lead I 4) ORS duration >211 ms Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology, Circulation 2012;126:1752-1769 Cardiomyopathy & Transplantation: Gregg C. Fonarow MD Tamara Horwich MD Daniel Cruz MD Arnold Baas MD Mario Deng MD Ali Nsair MD ACHD: Ravi Mandapati MD Jamil Aboulhosn MD Pamela Miner RN NP Cardiac Surgery: Hillel Laks MD Murray Kwon MD Richard Shemin MD Peyman Benharash MD Curtis Hunter MD Echocardiography: Barbara Natterson MD Aman Mahajan MD PhD Cardiac Anesthesia: Komal Patel MD Jonathan Ho MD Center Director Kalyanam Shivkumar MD PhD Co-Directors Noel G. Boyle MD PhD Aman Mahajan MD PhD Specialized Program for AF Eric F. Buch MD, MS, Dir Specialized Program for VT Jason Bradfield, MD, Dir Implanted Devices Clinic Osamu Fujimura MD, Dir Cardiac EP, UCLA Olive View Carlos Macias, MD Dir Clinical & Translational Research Marmar Vaseghi MD MS, Dir West Los Angeles-VAMC: Zenaida Feliciano MD, Dir Malcolm Bersohn MD Janet Han MD Electrophysiology Faculty: Olujimi A. Ajijola MD PhD Carlos Macias MD Ravi Mandapati MD EP Fellows/trainees: Jonathan Hoffman MD Houman Khakpour MD Yuliya Krokhaleva MD Tadanobu Irie MD PhD Una Buckley MD David Hamon MD Pradeep Rajendran BS (MSTP/PhD) Ray Chui BS (MCIP/PhD) Jeffrey L. Ardell PhD, Dir J. Andrew Armour MD PhD John Tompkins PhD Eileen So BS EP Nurse Practitioners: Shelly Cote RN MN NP Jean Gima RN MN NP Geraldine Pavez RN MN NP Research Administration: Julie M. Sorg RN MSN Radiology: J. Paul Finn MD PhD Stephen J. Kee MD John Moriarty MD Stefan Ruehm MD Administrative: Susana Morales Carmen Mora BS Julie Ramirez BS Health System: Laura Brandsen-Yost MSHA Erick Ascencio CVT Coach John R. Wooden 1910-2010 7 2/8/2016 Outcomes of Combined Epicardial and Endocardial Ablation Srinivas Dukkipati, MD Director, Electrophysiology Lab Icahn School of Medicine at Mount Sinai New York, NY Scar-Related VT d’Avila A et al. Heart Rhythm 2006 LV RV LV RV RF Myocardial Infarction • • • Coronary artery territory Subendocardial or transmural Epicardial scar present in ~10%1 Dilated Cardiomyopathy • • • • Mid-myocardial & epicardial, patchy or longitudinal striae Scar progression over time2 Basal – perivalvular3 Anteroseptal & inferolateral scar location in 89% of those with VT4 3HH 1Verma 2Liuba A et al. JCE 2005;16:465-71 I et al. Heart Rhythm 2014;11:755-62 et al. Circulation 2003; 108:704-10 S et al. Circ EP 2013;6:875-83 4Piers Disclosures • Biosense Webster – Research Grant 1 2/8/2016 Post-MI: Endo–Epicardial Homogenization Di Biase L et al – JACC 2012;60:132-41 • 100% non-inducibility achieved in both groups 81% 51% DCM: Endocardial Ablation Hsai HH et al – Circ 2003; 108:704-10 • 19 pts with DCM and MMVT – Basal (peri-mitral) scar in ALL – Endocardial scar <25% of LV – Of 57 VTs, 88% of induced VTs were from basal scar • After ablation, 14/19 (74%) were non-inducible • After 22 ± 12 months, only 5 pts (23%) were alive without VT recurrence DCM – Epicardial Scar Cano O et al – JACC 2009; 54:799-808. • 22 pts with DCM and failed prior endocardial ablation (n=20) or VT suggestive of epicardial origin (n=2) • Combined epicardial/endocardial mapping was performed • Scar Location Epicardial scar in 18 pts (82%) – basal LV/lateral wall Endocardial scar in 12 pts (54%) – basal LV • Scar Area Epicardial = 55.3 ± 33.5 cm2 Endocardial = 22.9 ± 32.4 cm2 (p < 0.01) • F/U 18 ± 7 months 71% free of VT 2 2/8/2016 Cano O et al. JACC 2009;54:799-808 Single Procedure VT-free Survival: ICM vs. NICM VT-free Survival at 1 year: ICM = 57%, Results From the Prospective NICM = 40.5% Heart Centre of Leipzig VT (HELP-VT) Study Dinov B et al – Circulation 2014;129:728-36 • 224 pts. (ICM 164, NICM 63) • Epicardial ablation: ICM 1.2% NICM 30.8% • Acute procedural success (noninducibility of VT): ICM 77.4% NICM 66.7% VT-free Survival at 1 year: ICM = 57%, NICM = 40.5% Circ EP 2014;7:414-23 • 87 pts. with NICM and VT: Anteroseptal scar 44 inferolateral 43 • Presence of anteroseptal scar was associated with a HR 5.5 (p<0.001) for VT recurrence ECM: early CM DCM: LVEF<45%, mod-severe LV dilatation 3 2/8/2016 Transcoronary Ethanol Ablation VT Termination BIPOLAR RFA INFUSION NEEDLE ABLATION Sapp J L et al. Circ 2013;128:2289-2295 Koruth JS et al. Heart Rhythm 2012;9:1932-41 HCM ARVC RV AP Burke - http://emedicine.medscape.com RV ENDOCARDIAL EPICARDIAL Cardiac Sarcoidosis Dubrey SW et al. Prog Cardiovasc Dis 2010;52:336-46 4 2/8/2016 Hypertrophic Cardiomyopathy Circ EP 2011;4:185-194 Heart Rhythm 2010;7:1036-42 • 10 pts. with HCM & drug refractory VT undergoing combined epicardial-endocardial ablation • • Epicardial scar present in 8/10 (80%) • Epicardial RFA in 13 pts (59%) • Acute procedural success: 89% • Acute procedural success: 86% • At 37 ± 17 months – 78% VT free • At 20 ± 9 months – 73% VT free 22 pts with HCM & drug refractory VT undergoing catheter ablation ARVC-VT: Endocardial Ablation Dalal et al JACC 50:432, 2007 ARVC-VT: Combined Endocardial & Epicardial Ablation Santangeli P et al – Circ EP 2015;8:1413-21 • 62 pts. with ARVC-VT undergoing endocardial ± epicardial ablation • Follow-up 56 ± 44 months VT Frequency Freedom from Ventricular Arrhythmias 71% 5 2/8/2016 VT-free Survival at 1 year: ICM = 57%, NICM = 40.5% Circ EP 2012;5:992-1000 • 224 pts. with NICM and VT: • Epicardial ablation: • • • • • • • DCM 29% ARVC 30% Sarcoidosis 15% HCM 43% Congenital 6% Valvular 3% Secondary endpoint: freedom from death, transplantation, VT hospitalization Final Thoughts • Unlike in ischemic VT, scar in other substrates is NOT predominantly limited to the sub-endocardium • Epicardial scar present in: ICM ~10% other substrates ≥ 30% • An endocardial ± epicardial ablation approach best results in ICM and ARVC suboptimal results in DCM (inferolateral scar better than anteroseptal scar) and Cardiac Sarcoidosis • Better mapping and ablation technologies are necessary to improve outcomes 6 2/8/2016 Role of Imaging Techniques in Catheter Ablation of Ventricular Tachycardia Amin Al-Ahmad, MD, FACC, FHRS, CCDS Texas Cardiac Arrhythmia Institute Austin, Texas Disclosures • • • • • • Medtronic St Jude Medical Boston Scientific Biosense Apama Medical Khalila Medical Introduction • Pathophysiology of VT in complex • Interplay between substrate, triggers • Understanding the substrate is helpful in targeting VT • Imaging during procedures to guide in ablation and prevent compliactions 1 2/8/2016 Pre-Procedural Imaging • Nuclear – Perfusion – Viability – Innervation • MRI – Late enhancement • CT scan/Rotational Fluoroscopy Rijnierse et al. JNC 2015 2 2/8/2016 Rijnierse et al. JNC 2015 Perez-David JACC 2011 Perez-David JACC 2011 3 2/8/2016 Desjardins et al. HR 2009 Fernandez-Armenta et al. Circ A&E 2013 Dickfeld et al. Circ A&E 2011 4 2/8/2016 CT Scan- Wall thinning Komatsu et al. Circ A&E 2013 Cochet et al. JCE 2013 Image of LV scar- Rotational Fluoroscopy Day 0 Day 30 Visualization of RF Lesions--Rotational Fluoroscopy • 29 RF ablation lesions were created and visualized • All lesions exhibited a perfusion defect • 24 lesions (83%) had a peripheral enhancing ring Girard E, Al-Ahmad A. et al. JACC Imaging 4(3): 259-268, 2011 5 2/8/2016 Procedural Imaging • ICE – 2D – 3D • Fluoroscopy registration tools ICE for VT • Placement of the ICE catheter in the RA or RV or pericardium allows visualization of the left ventricle – Structures: • papillary muscle • false tendon • valves • coronary arteries 6 2/8/2016 3D Reconstructed Images 7 2/8/2016 Vaseghi et al, HeartRhythm 2006 8 2/8/2016 ICE for VT • Visualization of areas of wall thinning or wall motion abnormalities Epicardial Scar Unipolar voltage ICE Image 9 2/8/2016 Epicardial VT Interventional MRI Real-time guidance of a passive catheter to the His bundle position in the canine model. A, Catheter bipolar electrodes (Bi) are shown in the inferior vena cava. B, The catheter is advanced, with tip (arrow) entering hepatic vein. C, Catheter buckling as a result of advancement into a hepatic vein. D, The catheter tip is withdrawn into the inferior vena cava. E, The catheter tip is advanced beyond the hepatic vein branch in the inferior vena cava. F, The catheter tip is advanced to the tricuspid annulus. SVC indicates superior vena cava; L, liver; RV, right ventricle; and RA, right atrium. Nazarian S, et al. Circulation. 2008 10 2/8/2016 Conclusions • Pre-procedural imaging is helpful in gaining insight into stuructural and functional substrate for VT • CT and MRI correlate well with EA mapping • Intra-cardiac ultrasound is valuable during VT ablation for identifying substrate, catheter location and preventing complications Thank You 11 2/2/2016 Epicardial Mapping and Ablation Techniques: How to Prevent and Manage Complications Mathew D. Hutchinson, MD Associate Professor of Medicine University of Pennsylvania Disclosures Within the past 12 months, I have received modest financial support from the following entities: 1. Medtronic- lecture honoraria 2. Biosense Webster- advisory panel 3. Abiomed- lecture honoraria Perioperative considerations • Patient selection – Habitus – Prior surgery, pericarditis • Hematologic issues Pericardial access complications N Acute Chronic Sacher et al. 156 5.1% 1.9% Tung et al. 109 8.8% NR Della Bella et al. 218 2.3% 1.8% Piers et al. 29 7% 3% Sacher et al. J Am Coll Cardiol 2010; 55:2366-72 Tung et al. Heart Rhythm 2013; 10:490-498 Della Bella et al. Circ Arrhythm Electrophysiol 2011; 4:653-9 Piers et al. Circ Arrhythm Electrophysiol 2013; 6:513-521 – Anticoagulation management – Blood products • Equipment – Access-related – Coronary angiography – Phrenic protection • Surgical backup 1 2/2/2016 Anatomy of the approach Flat Lateral LV RV Anterior Larrey’s Space LV RV Liver Catheter RAO 30º Tricks and tips LAO 40º LV RV 1. Needle techniques Apex 2. Define cardiac border LAO 50º AP 3. Use ICE, contrast 4. Don’t panic with RV perf LV 5. Confirm guidewire position RV 6. Maintain sheath hygiene Anterior Phrenic N Internal Thoracic Access-related complications Inferior Phrenic A Musculophrenic Superior Epigastric Rectus Abdominus • Superficial vessels • Abdominal viscera • Cardiac chambers • Epicardial vessels RV LV L Pleural Cavity Ross et al. Heart Rhythm 2011; 8:318-21 2 2/2/2016 Approach-specific complications Koruth et al. Heart Rhythm 2011; 8:1652-7 Anterior: In-and-out RV perforation Posterior: Liver laceration Ablation-related coronary injury Intimal hyperplasia • Presentation • Acute occlusion, spasm • Chronic stenosis • Likelihood of vessel injury: • Proximity to vessel (<2mm) • Internal diameter (<1.8mm) • Energy source (RF>cryo) Hypotension during RF D’Avila et al. PACE 2002; 25:1488-92 Lustgarten et al. Heart Rhythm 2005; 2:82-90 Phrenic nerve protection Non-compliant balloon 18x40 B B LV LV LV Diaphragm Diaphragm Phrenic capture at 20mA Fan et al. Heart Rhythm 2009 6(1): 59-64 • • • • Double pericardial access required Consider steerable sheath Position ablator between LV and balloon Alternative air +/- fluid- increased DFT 3 2/2/2016 Re-access after pericarditis/cardiac surgery • 28 pts; 4-9% total epi procedures • Acute success 17/28 • 100% with adhesions (anterior post surgical) • Blunt dissection required for mapping; deflectable sheath • Complications: ~10% (no deaths) Sosa et al. J Interv Card Electr 2004; 10:281-288 Roberts-Thompson et al. J Cardiovasc Electrophysiol 2010; 21:406-411 Tschabrunn et al. Heart Rhythm 2013; 10:165-169 Summary- Epi access complications • Relatively high complication rate • Adequate planning and equipment is essential to success • Complications specific to timing and approach • Develop a specific technique, but modify it as required Thank You! 4 2/2/2016 5
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