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Ventricular tachycardia_lecture
1. Outflow tract VT is the most common type of idiopathic VT, accounting for over 60% of cases in the study. 2. Pace mapping alone may not accurately locate ablation sites, especially for VT associated with scar tissue. Activation mapping and substrate identification are important complementary mapping techniques. 3. Successful ablation of substrate-based VT requires targeting abnormal electrograms within scar regions like late potentials or fractionated signals at the critical isthmus.
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Ventricular tachycardia_lecture
- 1. Ventricular Tachycardia 林彥璋 醫師, Lin Yenn-Jiang MD. Chen Shih-Ann MD. April 24, 2011 Advanced EP training, THRS St. Jude Medical, Taipei Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
- 2. Experience of VTEPS/ABL in Taipei VGH 2000-2010 Outflow tract VT : 121 : 61% Fascicular VT : 24:12% ARVC :18: 9% CAD : 18: 9% DCM : 8: 4%
- 3. P=0.007 Survival curve ofVT patients (N=200) Fascicular VT RVOT ARVC CPVT, idiopathic VF Ischemic VT DCM
- 4. How to MapVT Mapping Basic electrophysiologic study Pace mapping Activation mapping Electroanatomic mapping Ablation: RV, LV, and Epicardium
- 5. Outlines Outflow tract VT ARVC FascicularVT Substrate VT
- 6. Outflow Tract Ventricular Tachycardia (OT-VT) VT arises from the right ventricular outflow tract (RVOT-VT, left ventricular outflow tract (LVOT-VT), aortic cusps (Cusp VT), and from the pulmonary artery (PA VT) OT-VT tend to occur in the absence of structural heart disease and are focal in origin, the 12-lead ECG recorded during VT is a precise localizing tool.
- 7. Clinical Features ofRVOT-VT RVOT VT constitutes 75% of all patients with outflow tract VT RVOT VT is more common in females 30- 50 years old. Symptoms include palpitations, dizziness, atypical chest pain, and syncope. Exercise testing reproduces the patient’s clinical VT 25 to 50% of the time.
- 8. Mechanism of RVOT-VT Mostforms of RVOT VT are sensitive to adenosine Most likely mechanism is catecholamine mediated DAD and triggered activity. Mediated by the activation of cyclic AMP. Can be induced in the EP lab with isoproterenol, aminophylline, atropine, and rapid burst pacing but rarely with programmed ventricular extrastimuli.
- 9. 1. Important overlapping nature of the outflow tract course! 2. RVOT and PA lie anterior and to the left of the LVOT and aorta.
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- 13. How to D/DRVOT and VT with ASC in origin
- 14. Cross over ofRVOT & LVOT region I: biphasic, V1 :W L R I: positive L V1 :RS R AP view Superior view David Callans JCE 2009
- 15. Aortic Cusp VTMorphology
- 16. LVOT and AorticCuspid VT VT arising from the LVOT shares similar characteristics to the RVOT VT because of a common embryonic origin. ECG: LBBB with inferior axis with small R- waves in V1 and early precordial transition (R/S 1 by V2 or V3) or RBBB morphology with inferior axis and S-wave in V6. Aortic cusp VT accounts for up to 21% of idiopathic VT. More commonly arises from the LCC, than the RCC and rarely arise from the NCC.
- 17. Tabatabaei and Asirvatham.Circ EP 2009;2:316-326
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- 19. Mapping Tool forOT-VT ECG morphology: Could be non-inducible Pacing morphology could be large area 2 cm2: different chamber, scar, or epicardium, Activation map More accurate: remain unsuccess: more mapping sites, epicardium, different energy sources,
- 20. Spontaneous PVC Pace Mapping Taipei VGH 2010
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- 22. Schema of theVentricular Arrhythmia Origin, Breakout Site, and Preferential Conduction From the LCC Origin to the RVOT or Left Ventricular Septum T. Yamada, et al JACC, 2007, Vol. 50, No. 9: 884-91
- 23. Difficulty in Pace Mapping in RVOT‐T With Scar A VT PM 1 PM 2 B RVOT 2 1 Septal wall Anterior wall Free wall Taipei VGH 2010
- 24. Requirement of NCM for VT mapping Pacing mapping may not sensitive to locate the sites of foci in certain patients with focal VT, in the presence of large scar area. VT could be non-sustained and unstable. It is difficult to map the entire chamber One beat analysis of dynamic substrate by NCM may be useful to treat these patients.
- 25. Ensite Array Location ＲＡＯ ＬＡＯ Taipei VGH 2010
- 26. RVOT VPC formthe LVZ border (Higa S: University of the Ryukyus, Okinawa, Japan) 2010 Taipei VGH
- 27. Conclusions Carefully ECGinterpretation and EP study to localize the optimum ablation site for VT. Usually not life threatening, and could be treated conservatively. 3D mapping system can be helpful (activation map or substrate map), but correct chamber, far- field sensing, preferential conduction need to be considered.
- 28. Outlines Outflow tract VT RVrelated VT and ARVC Fascicular VT Substrate VT
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- 30. Idiopathic RVOT-T Right ventricularoutflow tract tachycardia (RVOT-T) represents up to 10% of all ventricular tachycardias (VTs), and is considered as a benign disease. Symptoms: Ranging from none to palpitations, lightheadedness, dyspnea, or syncope. Arrhythmias: Frequent isolated PVCs, bursts of nonsustained VT, or sustained tachycardia often facilitated by catecholamines or exercise. Ablation: Acute success rate of focal ablation of RVOT-T is 65–97% with rare complications.
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- 33. Arrhythmogenic RV Dysplasia Cardiomyopathybegins in RV with poor contractile function and dilatation, progresses to LV finally. Histology: RV muscle becomes replaced by adipose and fibrous tissue. Arrhythmia: Re-entrant Type (scarring & late Potentials) with LBBB type ECG; ECG: Diffuse T wave inversion over precordial leads, and Epsilon Wave. Ablation: The effect of catheter ablation is temporizing, 1/3 epicardium, mostly reentry. Implanted cardioverter defibrillator (ICD) is the only reliable therapy for sudden cardiac death.
- 34. Task Force Criteria TF (Definite +) if meet 2 major or 1 major 2 minor criteria McKenna et al. 1994, BMJ
- 35. Long-term Outcome Mean follow-upperiod 23 ± 28 months (0.3 – 127) Cumulative Incidence Cumulative Incidence TF (-), 3.1% TF (-) : 14% TF (+) , 7.4% TF (+): 36%: P=0.511 P=0.019 Follow-Up Duration Follow-Up Duration All Cause Malignant Mortality arrhythmias
- 36. Conclusions Positive TFcriteria is important to diagnose ARVC/D and is specific to detect the future VF/ICD implantation/ CV mortality Malignant ventricular arrhythmia and late recurrences may occur in patients with mild or atypical form of arrhythmogenic RV cardiomyopathy.
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- 38. Outlines Outflow tract VT ARVC FascicularVT Substrate VT
- 39. Diastolic potential &Purkinje potential
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- 42. Where to Target Diastolicpotential (P1) in the midseptum of LV. P1-QRS=28-130 msec If P1 could not be identified, target the fused and earliest Purkinje potential (P2) Successful ablation revealed P1 during SR could be a marker of successful ablation.
- 43. Outlines Outflow tract VT ARVC FascicularVT Substrate VT
- 44. Structure heart relatedVT • BBRT • Ischemic heart disease (most common): mostly Endocardium • ARVC: Epi/Endo • Non-ischemic cardiomyopathy: Epi/Edno • Tetralogy of Fallot and other post operation patients: Endo
- 45. Substrate VT Identification ofthe critical ventricle to be targeted (voltage mapping). Identify the location of the scar (bipolar voltage <0.5 mV, unipolar PNV < 30%). Conventional entrainment techniques remain important.
- 46. Normal Electrogram Bipolar Eg:< 3 deflection, > 2 mV, < 70 msec, amplitude/duration<0.05
- 47. Bystander Outer loop
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- 49. Successful ablation site • Abnormal site: LVZ, pre-systolic potential, fractionated electrograms Pacing during VT • Concealed entrainment. • Critical isthmus: with – 30-70% of the critical isthmus Concealed Fusion (S-QRS) – Diastolic potentials PPI=TCL S-QRS/TCL PPI not =TCL PPI=TCL >70% 30-70% <30% Bystander Outer loop Critical isthmus Inner loop Exit or outer loop
- 50. Mapping of VentricularTachycardia Out-loop • Activation mapping: • Pacing mapping Inner-loop – For focal VT – For substrate VT: near the exit site – S-QRS > 40 msec: isthmus • Entrainment mapping: – Concealed entrain, with PPI=TCL – Outer loop vs. inner loop – Critical isthmus, > 40 msec, < 70% of S-QRS, > 22% of S-QRS interval • Substrate mapping: Scar mapping
- 51. Case 1 Ventricular Tachycardia RV ICD Lead Pacing
- 52. Bi-Ventricular Voltage Map LVZ LVZ LVZ Ablation site Lin YJ et al. HRS abstract 2009
- 53. Ischemic LV VT---Case1 The important to identify chamber to ablate RVOT Septum LV apex ICD Lead Lin YJ et al. HRS abstract 2009
- 54. Lin YJ etal. HRS abstract 2009
- 55. Ischemic LV VT‐‐‐Case 2 The important to identify the LVZ and exit site Tsai WC et al. JCE in revision, 2010
- 56. Case: Ischemic LV VT The important to identify the LVZ and exit site Abnormal Substrate Entrainment Exit, entrance site Diastolic potential Tsai and Chen, Circ J, 2011
- 57. Voltage Map duringSR (DSM 30%) Taipei VGH 2010
- 58. RVOT-T Patient Voltage of SR Spectral Analysis Activation of VT 3.5 cm from PV Successful site septum Free wall Eg during SR Scar in the free wall site
- 59. Conclusions Outflow tract VTis the commonest form of idiopathic VT. ECG morphology is important for localization of focal VT and exit site of substrate VT before 3 D mapping. Pacing mapping may not sensitive to locate the sites of foci in certain patients with focal VT, in the presence of large scar area. Substrate mapping and entrainment mapping are important for the substrate VT.