Usefulness of new imaging techniques


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SOLAECE corner. Venice arrhythmias 2013

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  • Añadir después de ésta los Kaplan del paper del Europace. Se ahorran DAIS.
  • Usefulness of new imaging techniques

    1. 1. Usefulness of new imaging techniques to identify complex arrhytmogenic substrates in the ventricle Venice Arrhythmias 2013 “SOLAECE Corner” Gerardo Rodríguez Diez MD National Medical Center “20 de Noviembre” ISSSTE. México D.F. SOLAECE Treasurer
    3. 3. Key points o Background o Ablation targets o New imaging techniques • ICE • ce-CMR o Conclusion
    4. 4. Background o Non structural heart disease (focal origin) • Increase Automaticity • Triggered activity (early or delayed afterdepolarizations) o Structural Heart disease (scar-related) • Ischemic or no Ischemic • Relative large reentry circuits • Complex substrates around the fibrosis scars or border zones
    5. 5. Ventricular Arrhythmias and Scar • Critical anatomic substrates sustaining VA’s, shows different degrees of fibrosis / scar (even in cases of focal origin) *90% of sustained VT’s are due to reentry involving an area of ventricular scar. 10% remaining are due to reentry or automaticity involving the Purkinje system. Pogwizd SM, et al. Circulation 1998. *Stevenson WG, Heart Rhythm 2013.
    6. 6. Targets for ablation o Conduction channels (CC’s) • • Bundles of viable myocardium inside scars that become part of reentrant circuit during VT Are located at any level of the myocardium wall with variable thickness and a 3D- structure
    7. 7. VT ablation targets o Electroanatomic maps (EAM) • • Is a depiction of cardiac anatomy (through a color-coded display of the intracardiac electrogam) Areas of interest • reduce electrogram amplitude in voltage maps o Normal Electrogram amplitude • >1.5mV o Border zone electrogram • 0.5-1.5 mV o Core scar • < 0.5 mV
    8. 8. Catheter Ablation of reentrant VT o Goal: Identification of critical isthmus of conduction that is part of the reentrant circuit
    9. 9. Conventional VT ablation limitations o o o o o Hemodynamic intolerance Multiple changing morphologies Hemodynamic collapse Noninducible VT during EP testing Recurrences (50-88%) o Identification of the underlying substrate using voltage mapping with 3D reconstruction point by point • It’s cumbersome • Requires considerable skill • It’s time consuming
    10. 10. Complex imaging techniques o Rationale • • • • Characterization of arrhythmogenic substrates Direct guidance and characterization of ablation lesions Early detection or prevention of procedural complications Earn time during procedure o Imaging techniques are for defining the anatomy o Intracardiac echocardiography (ICE) • Accurate to describing the anatomy o Contrast enhanced cardiac magnetic resonance (ce-CMR) • Accurate to identify CC’s into the core scar
    11. 11. Ablation with ICE o o Allow us to watch the ablation tip Identification of anatomic structures • • • o Coronary cuspids Papillary Muscle Akinetic and Scar zones Allow us to identify early complications during the procedure
    12. 12. Image ablation with ICE
    13. 13. Epicardial Ablation with ICE Bala et al. Cir Arrhythm Electrophysiol. 2011
    14. 14. ICE mapping o What we can´t do with ICE? • Identification of conduccion channels in Scar and Border zones
    15. 15. ce-CMR o Predictive value for ventricular arrhythmia • Inducibility • Mortality o Scar tissue characterization • Quantification • Heterogeneity
    16. 16. Non-invasive Assessment of Cardiac Fibrosis • Ce-Cardiac Magnetic Resonance • Prognostic value for arrhythmia inducibility and mortality • Scar tissue characterization (quantification / heterogeneity) Infarct Core Border Zone Normal myocardium
    17. 17. Quantitative/qualitative estimation of Cardiac Fibrosis High SCD risk patients Low SCD risk patients LVEF 35% LVEF 35% LVEF 35% LVEF 35% Fernández-Armenta J, Berruezo A, et al. Europace 2012.
    18. 18. Image processing Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
    19. 19. Scar-Anatomy and 3D Structure of Conducting Channels
    20. 20. Anatomy and Scar Integration
    21. 21. Scar - Anatomy and 3D Structure of Conducting Channels
    22. 22. Signal Intensity Maps o Myocardial wall thickness 10% and 25% • Border zone channel is suggested • Sequential activation of electrograms Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
    23. 23. Identification of Conduction channels
    24. 24. Endo and Epicardial maps
    25. 25. Signal Intensity maps (SI)
    26. 26. Limitations of ce-CMR o Image aquisition • • • • The partial volume effect The presence of ventricular arrhytmias Lack of adequate apneas Variability of gadolinium kinetics o Identification of channels in EAM is manual • CC branching with a trajectory hard to define o This technique larger and prospective studies
    27. 27. cc-CMR guided ablation
    28. 28. Summary • Continuous improvement in cardiac imaging for arrhythmias in last years – Diagnosis and risk stratification – Guiding interventions – Saving time and be more accurate • Evolution from gross anatomy to histology and function • Need for cooperation between cardiac imaging specialist and electrophisiologist
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