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Jacob Atié, MD, PhD, FESC
Prof of Cardiology Federal University of Rio de Janeiro
Director Arrhythmias Department
Clínica São Vicente [email protected]
What is New in Channelopathies and Purkinje Related Ventricular Arrhythmias?
Mapping and Ablation in Early Repolarization Syndromes
Federal University of Rio de Janeiro
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Prevalence and Characteristics of Early Repolarization in
the CASPER Registry 100 ptCardiac Arrest Survivals with Preserved Ejection fraction Registry
At least 2 leads J point elevation
Derval et al. JACC 2011;58:722-8
Prevalence and Characteristics of Early Repolarization in
the CASPER Registry
100 pt
Derval et al. JACC 2011;58:722-8
13/56 (23%)6/44 (9%)
Prevalence and Characteristics of Early Repolarization in
the CASPER Registry
100 pt
Derval et al. JACC 2011;58:722-8
13/56 (23%)6/44 (9%)
Role of the Purkinje Conducting System in
Triggering of Idiopathic VF
16 pt
RV purkinje Left purkinje
Haissaguerre et al. Lancet. 2002 Feb 23;359(9307):677-8.
12 – Purkinje
4 – muscular
Ablation
14 (88%)
no recurrence
Mapping and Ablation of VF Associated with
Long QT and Brugada Syndromes
Haissaguerre et al. Circulation 2003;108:925-928
Left purkinje origin
Long Term Follow-up of Idiopathic
Ventricular Fibrillationa Multicenter Study
Knecht et al. JACC 2009;54:522-8
6 Centers – 38pt
Triggering VPBs originated
Purkinje
Righ- 16 Left 14 Both 3
Myocardium 5 pt
During mean Fup 63 months
7/38 pt (18%) recurrence VF
Epicardial Electrogram of the RVOT in Pt
with Brugada Syndrome Using an epicardial lead
5 Pt
Gide wire Conus branch – RCA
After IC AAD
all pt presented epi late potential
Nagase et al. JACC 2002;39:1992-5
Epicardial Electrogram of the RVOT in Pt
with Brugada Syndrome Using an epicardial lead
5 Pt
Gide wire Conus branch – RCA
After IC AAD
all pt presented epi late potential
Nagase et al. JACC 2002;39:1992-5
Prevention of VF in Brugada Syndrome by Catheter
Ablation Over the Anterior RVOT epicardium
9 pt recurrent VF
Nademanee et al. Circulation 2011;123:1270-79
Double annotation MAP
Longest
duration
Fractionated potentials
Prevention of VF in Brugada Syndrome by Catheter
Ablation Over the Anterior RVOT epicardium
9 pt recurrent VF
Nademanee et al. Circulation 2011;123:1270-79
7/9 – non inducible after
ablation
Follow-up 20 + 6 months
no VF recurrence
Prevention of VF in Brugadda Syndrome by Catheter
Ablation Over the Anterior RVOT epicardium
9 pt recurrent VF
Insight into mechanism of Brugada Syndrome: Epicardial substrate
and modification during ajmaline testing
Sacher F. Heart Rhythm 2014;11:732-734
32 years man
VF – no trigger
Pentaray
ajmalinaFractionated potentials
Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
14 pt
EKG clinic
EKG lab
(A) Although the coved type ECG Brugada
Brugada J. Circ EP 2015;8:1373-81
Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Flecainide
Brugada J. Circ EP 2015;8:1373-81
Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Brugada J. Circ EP 2015;8:1373-81
Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Brugada J. Circ EP 2015;8:1373-81
Fractionated potential
Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Without Flecainide
With Flecainide
PRE After ABlation Follow-up
Brugada J. Circ EP 2015;8:1373-81
Coved type increasing during RF-Ablation
I
II
III
aVR
aVL
aVF
V1
V2
ST Elevation during RF delivery
V2 progressively loose the
down-sloped shapeRF Start After few RF application
V1starts to change morphology
as well
• Mean Fup: 22 + 16 months
• 25/30 pt (83% ) - free of VF recurrences and normal ECG
• Remaining 5 pt
• 2 pt continuous presence of ST elevation type I
• 3 pt with early repolarization
Long Term Outcome After Epicardial Ablation of Anterior
RVOT in Brugada Syndrome Pt
30 pt
Nademanee. HRS 2015
Pappone C. Circ Electr 2017;10:e005053
135 pt with Brugada syndrome
63 pt ICD and VT-VF
72 pt inducible VT-VF
32 y old, syncope induced VF
Pappone C. Circ Electr 2017;10:e005053
Homogenization
Outcome
Follow up – 10 months
2 recurrence VF – new ablation
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
52 pt with Early repolarization and VF
Eletroantomical mapping: sinus and VF
RV, LV, endo and epi mapping – CardioInsight - 252 electrodes
Phenotype:
Group I: Late depolarization abnormality (with electrical substrate)
Grou II: No late repolarization (12 pt)
Ia: Brugada syndrome pattern (33 pt)
Ib: ERS without Brugada S. (7 pt)
IB (with substrate no Brugada)
Early Repolarization Inferior leads
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
IB (with substrate no Brugada)
Substrate with low voltageEarly Repolarization Inferior leads
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
Late depolarization abnormality
Group II
No late potentials depolarization RV, LV, endo ,epi
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
Group II
No late potentials depolarization RV, LV, endo ,epi
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
No late potentials or low conduction
Group I A (Brugada Syndrome)
Fractionated late
Potencials
Group I A (Brugada Syndrome)
Rotational activity
during VF
Focal activity
during VF
Fractionated late
Potencials
Focal and Reentry activity – FV Correlates
with fractionated late potencials
Group I A (Brugada Syndrome)
Ablation
Effect of Ablation in VF
30 years old male
Previously healthy, no history of medication or drugs
Living donor for liver transplantation
During anesthesic induction – VF
More than 40 episodes
Morand, Atié ESC 2019
30 years old male
Previously healthy, no history of medication or drugs
Living donor for liver transplantation
During anesthesic induction – VF
More than 40 episodes
Morand, Atié ESC 2019
General anestesia, Amiodarone, Lidocaine, betabloker,
Ca Gluconate, Magnesium sulfate, Pacemaker,
Stellate ganglion block
Morand, Atié ESC 2019
45ms
Morand, Atié ESC 2019
Catheter Ablation
45ms
Morand, Atié ESC 2019
Catheter Ablation
• Ablation for Idiopathic VF – target short couple VPB
from left and right Purkinje and RVOT.
Conclusions
• Ablation for Idiopathic VF – target short couple VPB
from left and right Purkinje and RVOT.
• Ablation over anterior RVOT epicardium is effective
in preventing VF in Brugada Syndrome
Conclusions
• Ablation for Idiopathic VF – target short couple VPB
from left and right Purkinje and RVOT.
• Ablation over anterior RVOT epicardium is effective
in preventing VF in Brugada Syndrome
• Disapearence of Brugada ECG pattern is associated
with no recurrence of VF episodes
Conclusions
Conclusions:
In Brugada S. there is a relation between ECG
pattern, the extent of abnormal substrate and
VT/VF induction
Conclusions:
In Brugada S. there is a relation between ECG
pattern, the extent of abnormal substrate and
VT/VF induction
There are 2 phenotypes of Early Repolarization
with and without late depolarization
abnormalities. Ablation is effective to treat
symptomatic pts. (substrate or triggers in the
purkinje sites)
Thank you
Epicardial RF Ablation- Homogenization
Case 2
Epicardial Biopsy Surgical Ablation
Brugada Syndrome
5 pt
Nademanee. HRS 2015
Brugada Syndrome
Structural Normal
Heart?
Fibrosis
