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1. Catheter Ablation of
Ventricular Tachycardia
Lin Yenn-Jiang MD. Chen Shih-Ann MD.
April 15, 2012
Advanced EP training,
St. Jude Medical, Taipei
Taiwan Heart Rhythm Society
Division of Cardiology, Taipei Veterans General Hospital
and National Yang-Ming University, Taipei, Taiwan
2. Experience of VT EPS/ABL
in Taipei VGH 2001-2011
61%
DCM
12%
CAD
9%
ARVC
9%
OT
FVT VT 4%
2%
1%
1%
3. Survival of VT Patients According to National
Mortality Data Base of Taiwan (up to 2011)
P=0.007
Fascicular VT
RV-VT
ARVC
Brugada,VF
CAD, DCM
4. Different types of VT
Focal Type Reentrant Type
Mapping and ablation VT differ by underlying
Pace condition and tachycardia mechanism.
mapping, Activation map, Entrainment technique, substrate
Unipolar electrogram morphology mapping, Electrogram
characteristics
9. 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.
10. Clinical Features of RVOT-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.
11. Mechanism of RVOT-VT
Most forms 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.
13. Outflow Tract Anatomy
1. Important overlapping
nature of the outflow
tract course!
2. RVOT and PA lie
anterior and to the left
of the LVOT and aorta.
18. LVOT and Aortic Cuspid 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.
22. Mapping Tool for OT-VT
ECG morphology
Could be non-inducible
Pace mapping
Could be large area 2 cm2: different chamber, scar, or
epicardium,
Activation map
More accurate: remain unsuccess: more mapping sites,
epicardium, different energy sources,
25. Difficulty in Pace Mapping in RVOT-T (1)
A VT PM 1 PM 2 B
RVOT
2 1
Septal wall
Anterior wall
Free wall
Taipei VGH 2010
26. Difficulty in Pace Mapping in RVOT-T (2)
Schema of the Ventricular Arrhythmia Origin, Breakout Site, and
Preferential Conduction From the LCC to the RVOT
T. Yamada, et al
JACC, 2007,
Vol.
50, No. 9: 884-91
27. RVOT-T : 3D mapping
Voltage of SR Spectral Analysis Activation of VT
3.5 cm
from PV
Successful site
septum
Free
wall
0.018
0.016
Eg during SR 0.014
0.012
Scar in the free wall site 0.010
0.008
0.006
0.004
0.002
0.000
0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300
28. Summery
Carefully ECG interpretation 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.
30. Idiopathic RVOT-T
Right ventricular outflow 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.
31. Arrhythmogenic RV Dysplasia
Cardiomyopathy begins 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.
32. Task Force Criteria
TF (Definite +) if meet 2 major or 1 major 2 minor criteria
McKenna et al. 1994, BMJ
33. TF Criteria
Positive TF criteria 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.
38. Electrophysiology
Not Fulfilling TF
Definite ARVC
RVOT-T (RVOT-VT)
21.6%
P value
78.4%
Catheter mapping
RV ERP (msec) 215 ± 22 238 ± 32 0.016
Inducible sustained VT 24% 59% 0.001
Requirement of
53% 26% 0.016
isoproterenol infusion
Tachycardia cycle
315 ± 67 277 ± 94 0.109
length (msec)
3D mapping
Scar in the RVOT
37% 57% 0.416
(voltage <0.5 mV)
Scar in the RV body 47% 57% 0.697
Total RV conduction
129 ± 46 222 ± 77 <0.001
time (msec)
Chen SA et al. 2011 HRS abstract
39. Predictor of VT Recurrence
After Ablation in TF (-) Patients
VT VT Multivariat
Odds ratio
Factors recurrence recurrence e analysis
CI (95%)
(+) (-) P value
TF criteria (1 major
7.5
one minor, or 3 35% 13% 0.055
0.95-59
minors)
Substrate Mapping
5.9
RV body & free wall 46% 17% 0.047
1.02-34
scar
Distance to the
1.1
pulmonary valve 29±19 19±10 0.047
1.01-1.17
(cm)
The presence of Scar / Foci in FREE WALL
indicated future recurrence in TF (-) patients
Chen SA et al. 2010 HRS abstract
40. Long-Term Outcome
(Mean follow-up time for more than 2 years)
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
42. Summery of ARVC/D
The most specific criteria to predict the outcome of
ARVC patients: TF criteria.
Detection of atypical and early form of ARVC from
idiopathic RVOT-T: Substrate mapping.
Substrate characteristics of ARVC: Diffuse LVZ and
longer activation time, and abnormal substrate in the
Epi-endocardium; Tachycardia: both focal and
reentrant.
44. LV fascicular VT
Most common left ventricular VT
Morphology: RBBB pattern (post. fascicular type:
superior axis and LAD. incidence 90%; ant. fascicular
type: inferior axis, and RAD; incidence 10%)
is a reentrant VT that originates from the Purkinje
network near the left ant or posterior fascicle without
structural heart disease.
This VT can be ablated by the diastolic potentials (P1
or DP) or Purkinje potentials during VT.
50. Where to Target
P1 (DP) in the mid-septum of
LV (28-130 ms before QRS).
The earliest P1 is not required,
usually targeting the lower 1/3
of the P1 to avoid AVB.
If P1 could not be identified,
target the fused and earliest P2
(PP) near the exit site of the
tachycardia.
Perfect QRS match during
pace mapping may not be
required.
Anatomic-guided linear
ablation, longitudinal transect
the limb of FVT.
Conventional catheter is enough
52. LV Papillary M VT (PM-VT)
Catecholamine sensitive VT, arising from anterior
and posterior papillary muscle.
Relative benign course in the follow-up
Focal and non-reentrant in mechanism. Mostly
presented with burst VPCs, Extra-stimulation
induced VT (-), entrainment (-).
Require advanced imaging to locate the PM-VT
(angiography, TEE, ICE…)
Could required multiple site ablation and irrigated RF
to achieve long-term success.
59. Baseline EP characteristics: BBRVT
• BBRVT: Old patients ,
structure heart disease
• RBBB or LBBB,
• Reentry: PPI<30 at
RVapex, Critical delay of
His-Purkinje system
• HV longer than SR,
• HV during SR not normal
64. Substrate VT
Localization of chamber (RV, LV, or Epi)
Localization of the disease susbtrate..
Identify the circuits of VT/VF, potential
exit/entrance sites for VT/VF, by
activation/entrainment during VT/VF and
substrate during SR.
Determination of the targets for ablation.
65. Strategy for Substrate
VT/VF ablation
Mappable/ inducible VT: Identification of the
circuits and use of entrainment technique.
Unstable VT: substrate mapping during SR, use
device, AAD to slow the VT rate.
Non-inducible VT: substrate mapping, pace
mapping, consider autonomically or
ischemically/mediated VT
Ineffective ablation: energy source, extensive
ablation, or epi/intramural in origin.
66. 1. Localization of VT by ECG
Bundle branch morphology: RBB: LV, LBB: RV or
LV septum.
Superior and inferior axis: sup. and inferior LV
Precordial transition: dominant R: mitral to basal,
dominant S: anterior apex in location.
Positive concordance: Mitral annulus, negative
concordance: LV apex.
Slurred wave, wider QRS, Q wave of lateral leads
for LV-VT, R wave in RV-VT: Epicardial in position.
74. Ischemic LV VT---Case 2
The important to identify the LVZ and critical
Channels and exit site
Tsai and Chen, Circ J, 2011
75. Conclusions
Outflow tract VT is the commonest form of
idiopathic VT.
ECG morphology is important for localization
of focal VT and exit site of substrate VT.
Pacing mapping may not sensitive to locate
the sites of foci in certain patients with focal
VT, scar-VT, epicardial VT, and fascicular VT.
In the stable VT of abnormal ventricular
substrate: activation maps and entrainment
technique are important to decide the targets.
In unstable VT, VF, and non-inducible VT,
substrate mapping during SR could be identify
to determine the critical substrate.
79. Changes in ECG during the procedure
Before epicardial puncture After epicardial puncture
Editor's Notes
Most outflow tract tachycardias originate in perivalvular tissue, which may be anatomically predisposed to fiber disruption that enhances arrhythmogenesis. In addition, the proximity of the outflow tract to the epicardial fat pads containing the ganglionated plexuses and the unique response to exercise and hormonal changes suggest that the autonomic nervous system also plays a role in this arrhythmogenesis.
Lerman et al have shown that most forms of RVOT VT are sensitive to adenosine and the most likely mechanism is catecholamine mediated delayed afterdepolarizations and triggered activity. Mediated by the activation of cyclic AMP that causes an increase in intracellular calcium and an oscillatory release of calcium from sarcoplasmic reticulum.
The right coronary cusp (RCC) of the aortic valve is directly posterior to the thick posterior infundibular portion of the RVOT. The true septum of the RVOT is not leftward but rather posterior and similarly, the septal portion of the LVOT is its anterior portion, just behind the RVOT. catheter placed in the RCC will record a large amplitude ventricular electrogram, the origin of which is mainly the right ventricular myocardium and partly the supravalvar left ventricular myocardium Recordings from the left coronary cusp (LCC) may map a supravalvar left ventricular myocardium, portions of the distal peripulmonary valve, posterior right myocardium, as well as the mitral annular left ventricular myocardium. The noncoronary cusp (NCC) of the aortic valve generally is surrounded only by atrial structures, and thus, mapping in the NCC will identify predominately atrial signals that may arise either from the right atrium, left atrium, or the interatrial septum. Therefore, ablation in the NCC is rarely required for ventricular tachycardia, but more often for atrial tachycardias from these regions. However, supravalvar posterior left ventricular tachycardias can occasionally be ablated with a catheter placed in the depths of the NCC .
Figure 1 a: Endocast of a normal heart viewed from the front showing the crossover relationship between right and left ventricular outflow tracts (arrows). Dotted ovals represent the orifices of the pulmonary and aortic valves. b: Atrial chamber transected and pulmonary and aortic valves cut at the level of the sinutubular junctions. The heart viewed from the right and posterior shows the central location of the aortic valve. Note the near alignment between a closure line of the aortic valve with that of the tricuspid valve. Dotted line represents plane of the atrial septum. c: Epicardial fat removed to show the ventriculoarterial junction (dotted line) between the pulmonary sinuses and the infundibulum and the relationship between the infundibulum and the aortic sinuses. Open arrow indicates the aortic mound in the right atrium. Ao aorta; L left coronary aortic sinus; LAA left atrial appendage; LCA left coronary artery; LAD left anterior descending artery; LV left ventricle; MV mitral valve; N noncoronary aortic sinus; PT pulmonary trunk; R right coronary aortic sinus; RA right atrium; RAA right atrial appendage; RCA right coronary artery; RV right ventricle; TV tricuspid valve. the RVOT region is seen wrapping around the root of the aorta and extending leftward. The top of the RVOT may be convex or crescent shaped, with the posteroseptal region directed rightward and the anteroseptal region directed leftward. The anteroseptal aspect of the RVOT actually is located in close proximity to the LV epicardium, adjacent to the anterior interventricular vein and in proximity to the left anterior descending coronary artery. The aortic valve cusps sit squarely within the crescent-shaped septal region of the RVOT and are inferior to the pulmonic valve. The posteroseptal aspect of the RVOT is adjacent to the region of the right coronary cusp, and the anterior septal surface is adjacent to the anterior margin of the right coronary cusp or the medial aspect of the left coronary cusp.
LVOT VT arising from the septal parahisian region has a ECG pattern of QS or Qr in V1 with early precordial transition and ratio of QRS in leads II/III 1, while LVOT VT arising from the aortomitral continuity has a characteristic qR pattern in V1 with a ratio of QRS in leads II/III
Ventricular arrhythmias originating from the ASC often show preferential conduction to the RVOT, which may render pace mapping or some algorithms using the electrocardiographic characteristics less reliable. In some of those cases, an insulated myocardial fiber across the ventricular outflow septum may exist. schema corresponding to the group 2 cases. (B) A schema corresponding to the group 1 cases. (C) A schema corresponding to the group 3 cases. LAD left anterior descending coronary artery; LCX left circumflex coronary artery; NCC noncoronary sinus cusp; RCC right coronary sinus cusp; other abbreviations as in Figures 1 and 2. In 8 of those 15 patients (group 1), the pace map score in the ASC was 20, whereas that in the RVOT was 13. However, in 4 of those 15 patients (group 2), the pace map score in the RVOT was 20, whereas that in the ASC was 15 (Table 1,Fig. 2). In 3 of those 15 patients (group 3), the pace map score was poor (12) in the ASC as well as in the RVOT. an excellent pace map in the ASC and a very poor pace map in the RVOT were obtained. In those cases, there should have been no myocardial fibers from the ASC origin to the RVOT because those myocardial fibers could not have reproduced an excellent pace map in the ASC for the same reasons as in the cases with a preferential conduction from the ASC origin to the RVOT (Fig. 5B) there should also be myocardial fibers traveling from the ASC origin to the left ventricular septum (Fig. 5A). Second, the pacing might capture the myocardial fibers from the ASC origin that not only extended to the RVOT but also to the left ventricular septum and thus diminish the preferential conduction from the ASC origin to the RVOT (Fig. 5A). a very poor pace map was obtained in both the RVOT and the ASC. There might have been some combined mechanisms that would have explained those findings. First, a preferential conduction from the ASC origin and not to the RVOT, but to the left ventricular septum should exist in those cases (Fig. 5C).
In all patients, we performed 3D endocadial mapping during sinus rhythm. We identified the area of LVZ with a electrogram voltage of less than 0.5 mV
1. RVOT VT is the most common type of idiopathic ventricular arrhythmia. Generally, 70-90% of the patients do not have structural heart disease, and si considered a a benign disease. 2. We hypothesize the patients not fullfilling the RF criteria of RV dysplasia are also at risk of VT recurrence and sudden cardiac death.
1. RVOT VT is the most common type of idiopathic ventricular arrhythmia. Generally, 70-90% of the patients do not have structural heart disease, and si considered a a benign disease. 2. We hypothesize the patients not fullfilling the RF criteria of RV dysplasia are also at risk of VT recurrence and sudden cardiac death.
In 1994, An international Task Force proposed criteria for the clinical diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia that facilitate recognition and interpretation of the nonspecific features of ARVC. There are 5 categories, including structural, histological, ECG, arrhythmic, and family history of the disease, inoperative in a major criteria and minor criteria based on the specificity of ARVD. This 1994 criteria were highly specific; However, this symptomatic index or sudden cardiac death may be the end stage of this disease
八十九歲男性病患,
Figure 1
RBBB, 2 with left superior axis, 5 with right superior axis
SINUS TACHYCARDIA. RUN OF VENTRICULAR PREMATURE COMPLEXES. SINUS PAUSE/ARREST W/ SUPRAVENTRICULAR ESCAPE. CONSIDER LEFT ATRIAL ABNORMALITY. RBBB AND LAFB. SR with VPCs and bi-directional VPCs
VPC maps was performed show earliest site at the posteroseptal mitral annul us base.
In conclusion, the noncontact mapping provides accurate global unipolar Eg and resultant isopotential maps throughout the chamber. It is an useful guide for mapping and guide ablation of unstable, nonsustained, and multiple focal tachycardia from one-beat analysis.
In conclusion, the noncontact mapping provides accurate global unipolar Eg and resultant isopotential maps throughout the chamber. It is an useful guide for mapping and guide ablation of unstable, nonsustained, and multiple focal tachycardia from one-beat analysis.
In conclusion, the noncontact mapping provides accurate global unipolar Eg and resultant isopotential maps throughout the chamber. It is an useful guide for mapping and guide ablation of unstable, nonsustained, and multiple focal tachycardia from one-beat analysis.