Aula sobre Taquicardia Ventricular relacionada à Cicatriz, ministrada pelo Dr. André D´Avila (CRM/SC 4797), no I Simpósio Catarinense de Arritmia Cardíaca, realizado em Julho de 2017, em Florianópolis - SC. O evento, promovido pela Clínica Ritmo, clínica especializada no tratamento de Arritmias e Implante de Marcapasso, teve como objetivo abordar todas as formas de arritmias cardíacas e as possibilidades de tratamentos, com temas trazidos a partir de casos reais tratados pelos especialistas da Clínica Ritmo nos últimos cinco anos. Para saber mais sobre os procedimentos, acesse: http://www.clinicaritmo.com.br/

1. Male, 58 yo, CHF II/III, LVEF = 32%, Syncope and VT
1. AAD
2. RFA
3. ICD
4. Surgery
5. All of the above
but Surgery
6. I don’t know
7. I don’t care

2. Scar-Related VT: ICDs Are Not a Cure
– High-voltage shocks are painful
– Up to 1/3 with depression
– Concomitant Drug therapy
• Needed in 39%-70% of patients
• ICD therapy nonetheless occurs
(exceeds 30%)
– Pts still die of Sudden Death
• 2% of VT/VF episodes are
refractory to appropriately
delivered ICD therapy (Am J
Cardiol 1998; 82:875-80
ICD shocks increase mortality
Frames provided by Bill Stevenson, MD

3. Double-Plicature Technique as Suggested by Jatene
d’Avila, Scanavacca and Sosa -JCE - 1998; 9: 1133

4. 16
2
13
18
10
46
39
7
PRE POST PRE POST
24
24
29
34
39
43
39
48
15
25
40
26
50
50
49
46
JCE - 1998; 9: 1133
Long Term Results: Double-Plicature Technique

5. JCE - 1998; 9: 1133
Long Term Results: Double-Plicature Technique
• No VT
• No Ischemia
• Better LVEF

6. Why Catheter Ablation of
Scar-Related VT
VT Surgery:
1. Very few speciailized centers and
2. High morbidity/mortality
RF
RF
LV
RV
Catheter Ablation: ???Surgery
X

7. Catheter Ablation of Ventricular Tachycardia

8. Post-MI Ventricular Tachycardia
Ca
RAO
LCA
RCA
150 bpm
70 bpm
V1
V6
I
II
III
aVL
aVR
aVF
Mapping Potential Channels
during Sinus Rhythm

9. 120 130 130 280
Sinus
Rhythm
RV
Pacing
VT Induction
with EP
S1 S1 S2
Isolated
Late
Potentials
Mid
Diastolic
Potential
I
II
III
V1
V6
LV
LV
285
400
Mapping Potential Channels during Sinus Rhythm

10. I
II
III
V1
V6
LV
LV
RF on
Post-MI Ventricular Tachycardia
285
400
Mid
Diastolic
Potential
Mapping Potential Channels during Sinus Rhythm

11. IRRIGATED Trial
(n = 251)
VTACH-1
(107)
SMASH VT
(128)
LVEF 0.25 0.34 0.30
Major
Complication
Vascular - 4.7%
HF – 7.3 %
1 STEMI
1 Stroke NO
Procedure
Mortality
(3%)
7 deaths * ZERO ZERO
Complications of Endocardial Ablation
for post MI VT
•The remaining death occurred in a patient who suffered cardiac perforation and tamponade after sitting up abruptly
during the procedure, followed by right coronary occlusion and cardiogenic shock.
Total = 486 pts and 36 centers – USA and UE

12. Case Strategy:
1. Distal CS + RV + ICE
2. Transeptal Access
3. Deflectable Sheath
4. Right Femoral Access
Male 68 yr, bicuspid AoV
• Ross Procedure 1993
• Porcine AV in 2008
• LVEF = 34% / ICD in 2005
• PPM Dependent
• 16000 episodes of Slow VT
2 Previous Procedures:
• Inducible VT
• RVOT : No Good EGMS
• Could not cross the AoV
VT

13. Site of First RFA
RAOLAO

14. Bipolar Voltage Map
Endocardial LV Maps During RV Apex Pacing
Activation Map
RV Pacing

16. 258 msec 510 msec

17. VT Case
1st Degree AV Block
Case Report:
• 71 yo, male, ICD in 2006 for VT
• Angio with RLP occlusion
• LVEF = 45%
• 2 ICD Therapies last 12 mo
RV for Stim
ICE
Transeptal for LV Map
Define Substrate Before Induction
Induction with no Hemo Support
Procedure Plan:

18. Site for First
Application
Fusion
PPI =90 ms
Fusion in V1 and
Interruption with no Capture
Same Spot
Taken in NSR
RF # 1
RF # 1

19. Termination within 11 sec
RF on

20. Final Lesion Set
Non-Inducible with Triplets and 350 ms Burst from RV
and LV

21. RFA as primary management of well-tolerated VT
in pts with SHD and LVEF > 30%
European Heart Journal Advance Access published February 28, 2014

22. LV Inferior Wall Scar in Chagas’ Disease
LV
RV
Viable
Area
Fibroses
SCAR
- zoom -
Narrowing
Scar Thickness
3.9 ± 1.2 mm
(2.6 – 5.4 mm)

23. Prevalence of Epicardial Circuits
in Different Populations
< 20%
• NORMAL
• POST-MI
>20%
• ARVC
• HCM
• CHAGAS
• DCM
ARVC/HCM
CHAGAS
DCM
> 50%
40%
30%
20%
MI

24. Acesso ao Espaço Epicárdico:
Ausência de Derrame Pericárdico
Ablação Epicárdica de Taquicardia Ventricular

25. Complication Risk Factors
• Cardiac surgery
– Adhesions most
dense anteriorly
• Myocarditis
– Diffuse adhesions
• Disruption of adhesions using curve of deflected
Abl catheter feasible w/o major complications
J Interv Card Electrophysiol 2004; 10:281–8.
.
Surgical Window

26. PA
63 mm
AE AE
AP
AD
SC
Persistent SVC and CS VT = 337/ 355 / 383 ms – 4 VT in 2 mos
Male, 28 yo / ARVC at 12 – Persistent Left Superior Vena Cava
▪ Negative FH = 6 yo son e 32 yo sister (-)
▪ ICD in 2008 – Multiple therapies
▪ 600 mg amiodarona + 160 mg sotalol
▪ 4 failed endocardial ablations
✓ Amiodarone Phototosicity
✓ QTc = 680 msec
✓ Amiodarona induced Hyperthiroidism

27. Management of ARVC 2016
• Autosomal dominant, reduced penetrance and marked variable
expressivity.
• 2nd - 5th decade with symptoms associated with Vas.
• Equally common in men and women; men have a worse disease
course.
J Am Coll Cardiol 2014;64:119–25 1 in 1000 to 1 in 5,000

28. Bipolar Voltage Map / RV and LV Epicardial Surface
Right Ventricle
Apex
LV
AV
Ring

29. LV Scar
Left Lateral View
AP

30. Late and Very Late Potentials
382ms 370ms
150mm/seg 300mm/seg
220ms

31. Ablation of LP in ARVC
RF

32. Epicardial Activation Map
Before RF After RF

33. Kaplan–Meier curves for VT–free survival after
a single procedure: NIDCM vs ICM
Results From the Prospective Heart Centre of Leipzig VT (HELP-VT)
Study
Circulation. 2014;129:728-736
63 NIDCM
164 ICM
227 pts

34. Ventricular Tachycardia Ablation versus
Escalation
of Antiarrhythmic Drugs
N Engl J Med
2016;375:111-21.
259 pts / 1:1 Randomization / 27.9±17.1 mos of FU
Post-MI with an ICD
No Amio: 400 mg bid 1mo / 400mg qd 1 mo /200 mg/
day
< 300 mg of Amio: half loading + 300 mg per day
≥ 300 mg Amio: Amio + mexiletine 600 mg/day

35. In patients with ischemic
cardiomyopathy and an ICD
who had VT despite AAD
therapy, there was a
significantly lower rate of
the
composite primary outcome
of death, VT storm, or
appropriate ICD shock
among pts undergoing
catheter ablation than
among those escalating AAD
drug therapy
Conclusion:
N Engl J Med 2016;375:111-21.

36. Current Treatment for
Scar-Related VT
1. AAD – may be more toxic than helpful
2. Surgery – ideal approach but limited to very few
centers
3. ICD – excellent option to prevent sudden death
4. Catheter Ablation – best approach to prevent VT
recurrence: the earlier, the better!

37. Prophylactic Catheter Ablation for the
Prevention of Defibrillator Therapy – SMASH VT
Trial
N Engl J Med 2007;357:2657-65.
Follow-Up (2
years)
History of a MI
Cardiac Arrest
(VT/VF)
Randomization
ICD
ICD +
Substrate
Ablation

38. Pts Treated with Catheter Ablation for VT after an ICD
Shock Have Lower Rates of Death and HF
Hospitalization
Compared to Medical Management
Mortality, HF hospitalization, AF
, Stroke/TIA.
a. 102 VT Abaltion + ICD
b. 1088 NO ICD Shocks
c. 817 ICD Shocks
Heart Rhythm, http://dx.doi.org/10.1016/j.hrthm.
2013.12.014

39. 18 centers - 142 post-MI pts - LVEF = .25 / HF = 65%
Circulation 2008;118:2773-82
The Multicenter VT Ablation Trial