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Electrical storm timing and approach for ablation
- 1. Electrical Storm: Appropriate Timing and Approach for Ablation Dr. Adelqui Peralta Director Cardiac Electrophysiology Boston VA Healthcare System Boston, MA, USA Assistant Professor of Medicine Harvard Medical School
- 2. Disclosures • None for this topic
- 3. Electrical Storm Triggers Arrhythmogenic Substrate Acute myocardial ischemia Electrolyte imbalances Decompensated heart failure Hyperthyroidism Infections, fever Pro-arrhythmic drug effects Early postoperative period Structural heart disease - ICM - NICMP Structurally normal heart Muser et al WJC 2017 Electrical Storm (ES) Life-threatening arrhythmic emergency Treatment includes a multidisciplinary approach
- 4. 2014 • Catheter ablation should be considered early after hospitalization (within 48 hrs) after the correction of triggers and a trial of antiarrhythmics.
- 5. Myocardial Scar Substrate for Reentrant VT Stable VTs: Entrainment & mapping
- 6. Scar Dechanneling Berruezo et al Circ Ep 2015 Substrate-based ablation Targeting conducting channels Before After
- 7. Scar Homogenization • Substrate-based ablation • Targets abnormal electrograms (fragmented, late, split) within the scar (defined at electroanatomic mapping) in sinus or paced rhythm • Endpoint is either elimination of abnormal electrograms or loss of local capture at high output pacing • Does not (necessarily) require VT induction or targetting clinical VT
- 8. Core Isolation Tzou et al Circ EP 2015
- 9. Muser et al WJC 2017 Role of Catheter Ablation in ES
- 10. • Prospective enrollment of 95 pts (72 CAD, 10 NICM, 13 ARVD) with AAD refractory • Acute elimination of ES in all pts • At 22 m, 87 (92%) pts free of ES and 63 (66%) free of VT recurrence. Carbuciccio et al Circulation 2008
- 11. Ventricular Arrhythmia/ICD Therapy-Free Survival by the Ablation Approach • 92 pts with ES and ICM FU 25 m VA recurrence: 47% vs 19%
- 12. Long Term Outcomes ES VT Ablation SHD ICM vs NICMP VA-Free Survival Survival Free of death/Tx Kumar et al JCE 2017
- 13. Long Term Outcomes VT Ablation SHD Electrical Storm vs No Storm ICMP NICM VA-Free Survival Survival Free of death/Tx Single Procedure ICMP VA-free survival @ 1 year ~ 50% NICMP VA-free survival @ 1 year 36% vs 47% Kumar et al JCE 2017
- 15. Procedural Characteristics and Acute Procedural Outcomes 54% @ 60m 62% @ 60m VT recurrence predictor: Inducibility of any VT with cycle length >250 ms at PES end of procedure
- 16. VT Ablation in ES Procedural Characteristics No Storm ES p Vergara et al Heart Rhythm 2017
- 17. VT Ablation in ESOverallsurvival.VT-freesurvival 32% vs 22% @ 1 y 20% vs 8% @ 1 y Vergara et al Heart Rhythm 2017
- 18. VT Ablation in ES Predictors of Death Vergara et al Heart Rhythm 2017
- 19. Treatment Antiarrhythmic Drugs Beta blockersAmiodarone Others PAINESD Score: High Risk? ICD Reprogramming Sedation +/- GA & mechanical ventilation (higher risk – unstable VTs) Yes: Mechanical hemodynamic support RF Ablation Sympathetic denervation Palliative care
- 20. PAINESD Score Pulmonary disease (chronic obstructive) 5 Age > 60 yr 3 Ischemic cardiomyopathy 6 NYHA class Ⅲ ot Ⅳ 6 Ejection fraction < 25% 3 Storm (VT) 5 Diabetes mellitus 3 Predicts the risk of peri-procedural acute hemodynamic decompensation and post-procedural mortality in patients undergoing scar-related VT RFA Low < 8 Medium 9-14 High >15 Risk Santangeli et al Circ EP 2015 Muser et al Heart Rhythm 2018
- 21. Summary § Catheter ablation during ES can be life saving; it is effective in controlling the index arrhythmia and reducing VT and ES recurrences § Ablation is recommended within 48 hrs after correction of triggers and administration of AAD § It has moderate long term efficacy, specially in NICMP § Multiple procedures can be required § The strategy for VT ablation is patient and operator dependent, with substrates such as NICMP requiring frequently epicardial mapping/ablation.
- 22. Thank You