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Christopher Woods, MD PhD
Peninsula-Sequoia Cardiac Electrophysiology
Palo Alto Medical Foundation
Ventricular Arrhythmias: Ablating Our Way Out of Cardiomyopathy
and Sudden Cardiac Death, Is this the Final Frontier?
R43 NIH grant for work investigating a novel arrhythmia mapping system
Disclosures
Ventricular Tachycardia
Manifestations of Ventricular Tachycardia (VT)
Premature Ventricular Contractions (PVCs) Non-sustained ventricular tachycardia (NSVT) 3 or more consecutive QRS
complexes of ventricular origin at rate of more than 100 bpm Sustained VT Lasts more than 30 seconds, usually requires intervention for
termination Monomorphic VT Uniform QRS configuration Polymorphic VT Beat to beat variation in QRS configuration Electrical storm > 3 VT/VF episodes in 24 hours
Clinical Consequences of VT, PVCs
Sudden cardiac arrest Cardiomyopathy Syncope, near syncope Palpitations
Deo R, Albert C. Circulation 2012;125:620-637
Monomorphic vs Polymorphic vs Fibrillation
Monomoprhic VT: Idiopathic Scar
Polymorphic VT: Ischemia Long QT syndrome Brugada syndrome Short coupled Torsades Short QT syndrome Catecholamine polymorphic VT Early Repolarization/Idiopathic VF
Ventricular Fibrillation
Monomorphic VT
Idiopathic VTFocal VT associated with structural heart diseaseRe-entry in Scar
Ischemic Cardiomyopathy Non-ischemic Cardiomyopathy
Idiopathic dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy (ARVC) Infiltrative cardiomyopathy- amyloidosis, sarcoidosis Chagas disease
Idiopathic VT or PVCs
Focal process without structural disease Localized by ECG 2/3 RVOT, most others LVOT
Mitral Annular PVCs Fasicular VT Papillary Muscle VT Epicardial VT with coronary venous system
Reason to treat: Symptoms PVC induced cardiomyopathy Catheter ablation can be curative
Circ Arrhythm Electrophysiol. 2012;5:229-236.
PVC Induced Cardiomyopathy
Niwano S, Heart. 2009;95: 12301237. ~20,000 per day
ECG/Holter
Echo
Stress Testing/cMRI
Radiofrequency Catheter Ablation
Ablation can be curative PVC 71927; 54% burden EF 33%
PVC 42; 0.05% EF 53%
2 seconds of ablation
23 year-old with near syncope
Focal VT from Aortic Valve Suture Ring Scar
In 20% of patients with structurally abnormal hearts referred to us for VT, the VT was focal AND NOT ASSOCIATED WITH SCAR
Ventricular Tachycardia Associated with Structural Heart Disease: Scar Based
ICD is mandatory in this population
Class I Recommendations for ICD Defibrillators Level of Evidence A ICM LVEF 35% >40 days post-MI, NYHA II or III ICM LVEF 30%, >40 days post-MI, NYHA I Survivors of Sudden Cardiac Arrest
Level of Evidence B NIDCM LVEF 35%, NYHA II or III ICM LVEF 35-40%, NSVT and inducible ventricular fibrillation or sustained ventricular tachycardia at electrophysiological study With structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable With syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study
Primary Prevention Trials
Sudden Cardiac Death in Heart Failure; NEJM 2005 Multicenter Automatic Defibrillator Implantation Trial; NEJM 2002
Two options for ICD
Transvenous ICD Subcutaneous ICD
TV leads1: 95-99% successful conversion 9.1% complication rate over 16 months
Lead displacement 3.1% Pneumothorax 1.1% hematoma 1.2%. Infection rate 1.5%. Lead failure 5-40% depending on trial
SubQ ICD 100 % successful conversion Complication-free rates were 97 and 94%, at 30 and 360 days NO electrode failures No S-ICDrelated endocarditis or bacteremia
1 Ezzat VA, etal OpenHeart 2015;
Circulation. 2008; 117: 2721-2723
JOURNAL OF T H E AMERICAN COL LE GE OF CARD IOLOGY VOL. 65, NO. 16, 2015
14,703 post-MI patients depressed EF
RCT looking at Rx of Valsartan
83% of SCA occurred after hospital discharge.
74% of those resuscitated in the first 30 days were alive at 1 year
1 Solomon SD, et al. Sudden Death in Patients with Myocardial Infarction and Left Ventricular Dysfunction, Heart Failure, or Both. NEJM 2005; 352: 2581-2588.
Valsartan in Acute Myocardial Infarction Trial Investigators (VALIANT trial)
It turns out, ICD Does Not Improve Survival Immediately after MI (first 40 days)
1. EF 40% on day 531 2. Non-sustained ventricular tachycardia
J Am Coll Cardiol. 2006;47(12):2477-2482 NEngl J Med 2009;361:1427-36
The Defibrillator in Acute Myocardial Infarction Trial (DINAMIT)
Immediate Risk Stratification Improves Survival (IRIS) trial
1. EF 35% on day 535 2. Depressed heart rate variability
LifeVest
No society guidelines No RCT yet 150 joule biphasic shock Patient may inhibit shock while
conscious Captures ECG 30 seconds before
event Stores up to 75 minutes of ECG
J Am Coll Cardiol. 2010;56(3):194-203.
Heart Rhythm, Vol 12, No 9, September 2015
2061 patients from 12 international Centers Predictors of VT recurrence: NICM NYHA status Epicardial ablation More induced VTs ICD Lower EF Electrical >2 antiarrhythmic drug
70% freedom @ 1 year
VT in Ischemic Cardiomyopathy in a patient with large inferior Anterior MI
VT in Idiopathic NICM
95% of VT is unstable
Epicardia VT
Epicardial Approach
Summary Ventricular tachycardia is an important cause of sudden cardiac arrest ECG characteristics can localize the site and origin of VT Idiopathic VT
Monomorphic VT / Frequent PVCs curable with catheter ablation Polymorphic VT treated with ICD and drugs
In structural heart disease, ICD therapy is indicated in patients with ICM LVEF 35% >40 days post-MI, NYHA II or III ICM LVEF 30%, >40 days post-MI, NYHA I
Management of VT associated with structural heart disease beta-blockers, antiarrhythmic drugs, ICD Catheter ablation is a very important palliative measure with ~60-70% one
year freedom from recurrent VT
Slide Number 1Slide Number 2Ventricular TachycardiaManifestations of Ventricular Tachycardia (VT)Clinical Consequences of VT, PVCsMonomorphic vs Polymorphic vs FibrillationMonomorphic VTIdiopathic VT or PVCsPVC Induced CardiomyopathySlide Number 10Radiofrequency Catheter AblationAblation can be curative23 year-old with near syncopeFocal VT from Aortic Valve Suture Ring ScarSlide Number 15Ventricular Tachycardia Associated with Structural Heart Disease:Scar BasedSlide Number 17Primary Prevention TrialsTwo options for ICDSlide Number 20Slide Number 21Slide Number 22LifeVestSlide Number 24Slide Number 25Slide Number 26VT in Ischemic Cardiomyopathy in a patient with large inferior Anterior MISlide Number 28Slide Number 29Slide Number 30Summary
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