Storm aritmico: la procedura di ablazione Catheter ablation of ventriculr arrhythmias in patients with electrical storm

1. San Raffaele Hospital - Milano - Italy
03.11.2022
Disclosures: none
ANMCO AREA ARITMIE
Pasquale Vergara MD, Ph-D
Storm Aritmico
La procedura di ablazione:
quale approccio per quale
paziente?

2. VT ablation in Electrical Storm

3. Whenshould we perform VT
ablation after Electrical Storm?

4. Hazard ratio (HR) for mortality according to ventricular arrhythmia burden
against the reference group of patients with no ventricular arrhythmia
Mortality after VT clusters Elsokkari Progress Cardiovasc Dis 2021; 66: 70–79
⇝Higher mortality risk in
higher numbers
of VA episodes within a
shorter cluster

5. Early ablation is associated with better outcome
⇝1: early (<30 days after the first documented VT)
⇝2: delayed (between 1 month and 1 year)
⇝3: very late (>1 year)
 Late (≥2 VTs with the 1st and most recent VT
separated by at least 1month
 Early (all others)
Dinov et al. Circ AE 2014;7:1144-51.
Early
Late
Frankel, et al. JCE 2011;22:1123-8

6. How to perform VT ablation
after Electrical Storm?

7. Electrical Storm #patients
International VT Ablation Center Collaborative Group 677 pts with ES vs 1262 without ES
San Raffaele Hospital, Italy
UCLA, Los Angeles, CA
University of Pennsylvania
Texas C A Institute, Austin, TX
Brigham & Women’s, Boston
Texas Heart Institute, TX
Dokkyo Medical Univ., Japan
Univ. of Colorado, Aurora, CO
Univ. of Minnesota, Minneapolis
Univ. of Maryland, Baltimore
Intermountain Heart Inst., UT
University of Kansas, KS
2061 pts with structural
heart disease referred
for CA of scar-related
VT from 12
international centers
No Storm VT Storm p value
# % mean SD # % mean SD
N (%) 1263 65.1 677 34.9
Age (y) 61.3± 13.6 64.4± 12.5 <0.001
Male 1084 85.9 603 89.1 0.048
ICM 641 50.8 370 54.7 0.1
LVEF (%) 35.2± 13.2 30.4± 13.4 <0.001
NYHA class <0.001
class I 405 33.0 144 21.8
class II 473 38.6 226 34.2
class III 313 25.5 216 32.7
class IV 35 2.9 74 11.2
CRT 294 23.7 211 32.2 <0.001
≥1 previous ablations 488 38.6 300 40.6 0.015
# previous VT ablations 0.5± 0.8 0.6± 0.9 0.022
Syncope 102 16.0 74 23.6 0.004
Prior heart surgery 358 29.5 209 32.0 0.3
Hypertension 617 45.4 353 40.2 0.038
Hyperlipemia 634 55.7 368 62.7 0.005
Atrial fibrillation 285 25.3 204 33.2 0.001
Diabetes 227 18.5 177 26.8 <0.001
Chronic Kidney disease 328 26.1 252 37.5 <0.001
Creatinine (mg/dL) 1.2± 0.6 1.4± 0.9 <0.001
Previous drug therapy
Class 1A AAD 17 1.4 26 4.1 <0.001
Class 1B AAD 166 14.0 155 24.7 <0.001
Class 1C AAD 57 4.8 24 3.8 0.3
Beta blockers 947 76.2 563 84.3 <0.001
Amiodarone 605 51.0 404 64.3 <0.001
Sotalol 161 13.6 75 11.9 0.3
2 or more AADs 183 15.4 154 24.5 <0.001
Vergara et al.
Heart Rhythm
2018;15:48–55

8. Electrical Storm #procedures
No Storm VT Storm p value
# SD % # SD %
N (%) 1263 60.8 677 32.8
Induced VTs per patient 1.9± 1.9 2.5±1.8 <0,001
0 175 13.9 40 5.9
1 419 33.2 188 27.8
2 283 22.4 158 23.3
3 153 12.1 106 15.7
≥4 150 32.2 156 52.7
Total RF time (min) 35.2± 28.0 46.0±32.4 <0,001
Total procedure time (min) 265.7± 110.3 296.1±119.1 <0,001
Hemodynamic support 50 4.6 44 9.0 0.001
Endocardial + Epicardial mapping 329 27.5 169 27.1 0.6
Only mappable VTs 374 44.5 225 43.2 0.5
Any mappable VT 508 60.5 320 61.4 0.7
Any unmappable VT 466 55.5 296 56.8 0.6
Acute ablation result
Absence of any inducible VTs 834 71.2 395 63.9 0.002
Only nonclinical VT still inducible 214 18.3 140 22.7 0.03
Clinical VT still inducible 86 7.3 43 7.0 ns
PES not repeated after ablation 38 3.2 40 6.5 0.002
Procedural complications 77 6.5 45 7.3 0.5
Death before Hospital discharge 18 1.4 42 6.2 <0,001
Vergara et al.
Heart Rhythm
2018;15:48–55
International VT Ablation Center Collaborative Group 677 pts with ES vs 1262 without ES
San Raffaele Hospital, Italy
UCLA, Los Angeles, CA
University of Pennsylvania
Texas C A Institute, Austin, TX
Brigham & Women’s, Boston
Texas Heart Institute, TX
Dokkyo Medical Univ., Japan
Univ. of Colorado, Aurora, CO
Univ. of Minnesota, Minneapolis
Univ. of Maryland, Baltimore
Intermountain Heart Inst., UT
University of Kansas, KS
2061 pts with structural
heart disease referred
for CA of scar-related
VT from 12
international centers
Fragile patients!
• Experienced team  2 operators
• Anesthesiology support
• Pre procedure planning
• Be fast! – alias fast mapping

9. ⇝12-leads VT ECG
How to perform VT ablation after ES

10. ⇝12-leads VT ECG
⇝Imaging?
» previously acquired MRI
» CT scan
• Substrate identification
• Procedure planning
• Merge with EAM
How to perform VT ablation after ES

11. 2022 CT & CARTO

12. ⇝12-leads VT ECG
⇝Imaging?
» previously acquired MRI
» CT scan
» Substrate identification
» Procedure planning
» Merge with EAM
⇝Epicardial mapping?
» ECG criteria
» Epicardial substrate @MRI
» High recommended in specific etiologies (ACM, DCM)
How to perform VT ablation after ES

13. What VTshould we ablate
after Electrical Storm?

14. VT ablation after ES #recurrence
VT Recurrence
Vergara et al.
Heart Rhythm 2018;15:48–55
No inducible VT @PES after ablation
Only non-clinical inducible VT
Not tested
Clinical inducible VT

15. VT ablation after ES #survival
Survival
No inducible VT @PES after ablation
Only non-clinical VT inducible
Not tested
Clinical inducible VT
Vergara et al.
Heart Rhythm 2018;15:48–55

16. Outcomes of VT
ablation in Electrical Storm?

17. VT ablation after ES #recurrence #survival
VT Recurrence Survival
Vergara et al.
Heart Rhythm 2018;15:48–55

18. I-VT Score
predicting VT ablation outcome
Vergara et al. Circulation AE 2018;11:e006730

19. DM
2.4;
30/103
LVEF<14
5.3;
8/9
No
0.09;
4/404
Prev-Abl
0.44;
11/217
Age≥80
2.6;
8/25
LVEF≥30
0.19; 15/621
LVEF<30
2; 134/589
No VT
1.2; 55/370
No DM
0.75; 25/267
Age<80
0.56;
17/242
Previous Abl?
DM?
Age?
LVEF≥14
2;
26/115
ES
4.7;
45/95
NT, NC-VT, C-VT
3.5; 79/219
No ES
2.5; 34/124
EF?
ES?
PES?
1;
149/1210
Hazard Ratio;
pts with event/pts in thegroup
LVEF?
Risk of death re-estimated after ablation Vergara CircAE 2018;11:e006730

20. Future
perspectives

21. Future perspectives
⇝Pre-procedure VT circuit
identification
⇝New energy sources for
transmural lesions
Noninvasive Cardiac Radiation for Ablation of VT
Cuculich et al.
N Engl J Med 2017;377:2325-36

22. Storm Aritmico – L’ablazione: quale approccio per quale paziente?
P. Vergara
⇝ L’ablazione transcatetere è una procedura
potenzialmente salvavita
⇝ Dopo lo storm aritmico l’ablazione va programmata il più
presto possibile
⇝ Accurata pianificazione preprocedurale
⇝ Dopo la procedura di ablazione è indispensabile ristratificare il rischio
di mortalità ed eventualmente pianificare trattamenti addizionali