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Mapping and Ablation of Challenging Outflow Tract VTs:

Pulmonary Artery, LVOT, Epicardial

Mapping and Ablation of Challenging Outflow Tract VTs:

Pulmonary Artery, LVOT, Epicardial

Samuel J. Asirvatham, MDMayo Clinic Rochester

California Heart Rhythm SymposiumSan Francisco, CA

September 8, 2012 – 1:45 PM

Samuel J. Asirvatham, MDMayo Clinic Rochester

California Heart Rhythm SymposiumSan Francisco, CA

September 8, 2012 – 1:45 PM

DisclosureDisclosure

I receive royalties for work licensed through Mayo Clinic to a privately held company for contributions related to the use of nerve signal modulation to treat central, autonomic, and peripheral nervous system disorders, including pain. Mayo Clinic receives royalties and owns equity in this company. The company does not currently license or manufacture any drug or device in the medical field.

Co-patent holder for technique to minimize coagulum formation during radiofrequency ablation

Products or techniques related to the above disclosures are not being discussed in this presentation.

Pertains to inventions/startup companies that include Nevro, Aegis, and the Phoenix Corp.

I receive royalties for work licensed through Mayo Clinic to a privately held company for contributions related to the use of nerve signal modulation to treat central, autonomic, and peripheral nervous system disorders, including pain. Mayo Clinic receives royalties and owns equity in this company. The company does not currently license or manufacture any drug or device in the medical field.

Co-patent holder for technique to minimize coagulum formation during radiofrequency ablation

Products or techniques related to the above disclosures are not being discussed in this presentation.

Pertains to inventions/startup companies that include Nevro, Aegis, and the Phoenix Corp.

Honoraria/Speakers:AbiomedBiotronikBlackwell FuturaBoston ScientificMedtronicSanofi-aventisSpectraneticsSt. Jude

Consulting:SanofiStereotaxis

VT AblationVT Ablation

CP1206111-1

Less difficultLess difficult More difficultMore difficult

Outflow tractOutflow tract FascicularFascicular

ValvarValvar

ARVDARVDLVLV PurkinjePurkinje

ReentryReentry

Anatomic targetAnatomic target

Sarcoid, etcSarcoid, etc

ScarsScarsMitral valveMitral valve

Have to mapHave to map

SystemSystem

EntrainmentEntrainment

ImagingImaging

ElectrophysiologyElectrophysiology

Lesion creationLesion creation

AnatomyAnatomy

Right Ventricular Outflow Tract VTRight Ventricular Outflow Tract VT

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Right Ventricular Outflow Tract VT (RVOT VT)

Right Ventricular Outflow Tract VT (RVOT VT)

• Left bundle branch block, inferior axis

• Typically exercise provoked

• May be sustained or in salvos

• Prognosis generally excellent

• Some are sensitive to beta blockers or Ca channel blockers

• Mapping based on earliest activation

• Left bundle branch block, inferior axis

• Typically exercise provoked

• May be sustained or in salvos

• Prognosis generally excellent

• Some are sensitive to beta blockers or Ca channel blockers

• Mapping based on earliest activation

26 yrs female, 25,000 PVCs on Holter 3 failed ablat ions3 Steps to Non Contact Map3 Steps to Non Contact Map

1. Define Geometry 2. Record Map 3. Guide catheter to critical map site

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LAO

Cardiac Vein

RVOT

LVOTretrograde approachLCX

LAD

Normal HeartDirection of Great Arteries

Normal HeartDirection of Great Arteries

Anterior View

RV

LV

Ao PA

• Pulmonary artery

Anterior to aortaTo left shoulder

• Ascending aorta

Posterior to PATo right shoulder

• Aorta-PA angle

60 to 90 degrees

Normal HeartVentricles

Normal HeartVentricles

Long-Axis View

RVOT

LV

Ao

LA

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Normal HeartValves & Coronary Arteries

Normal HeartValves & Coronary Arteries

Cardiac Base

MVTV

PV

AVLCX

LADRCA

CS

Conus

RCCRCC

PVPV Anteroseptal RVOTAnteroseptal RVOT

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Inlet-outlet ring aroundInlet-outlet ring aroundRight AV junction andRight AV junction and Outflow tractsOutflow tracts

Left AV junctionLeft AV junction

Trabecular componentof right ventricle

Trabecular componentof right ventricle

Left ventricleLeft ventricle

Ventricular bundle branches on apical trabecular septum

Ventricular bundle branches on apical trabecular septum

PrimaryseptumPrimaryseptum

Dead-end tractDead-end tract

AV groveAV grove

RightventricleRightventricle

AV groveAV grove

Compact nodeCompact node

Penetrating bundlePenetrating bundle

Dead-end tractDead-end tract

Branching bundle and bundle branchesBranching bundle and bundle branchesCP1041447-5

12-lead ECG12-lead ECG

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RVOT Anatomy LPO

Lasso in aortic-root

I

V1

V2

Lasso at aortic Sinus of ValsavaLasso at aortic Sinus of Valsava

Normal HeartExternal Topography

Normal HeartExternal Topography

Superior View

RAA

LAA

CP1052627-6

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Srivathsan K, AS G, Ackerman M, Asirvatham S: Treatment of ventricular fibrillation in a patient with prior diagnosis of long QT syndrome: importance of precise electrophysiologic diagnosis to successfully ablate the trigger. . Heart Rhythm 2007; 4:1090-1093.

Srivathsan K, AS G, Ackerman M, Asirvatham S: Treatment of ventricular fibrillation in a patient with prior diagnosis of long QT syndrome: importance of precise electrophysiologic diagnosis to successfully ablate the trigger. Heart Rhythm 2007; 4:1090-1093.

Liu XK, Barrett R, Packer DL, Asirvatham SJ: Successful management of recurrent ventricular tachycardia by electrical isolation of anterolateral papillary muscle. Heart Rhythm 2008; 5:479-482.

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Figure 1A

T2

T3

T4

Courtesy of Dr. Michael Ackerman

Imaging and Epicardial Procedures

Imaging and Epicardial Procedures

Left Ventricle, Epicardium, Acetone, LabVision (Kit)

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External Cardiac AnatomyPericardium

External Cardiac AnatomyPericardium

Illustration (CIBA) Heart Removed

VT in the “Normal Heart”VT in the “Normal Heart”

1. Right ventricular dysplasia

2. Sarcoidosis

3. Cardiomyopathy, not tachycardia related

4. Coronary vascular malformation

5. Mitral valve prolapse

6. False tendon/moderator band

7. Non-compact myocardium

8. Atypical ventricular dysplasia pattern

1. Right ventricular dysplasia

2. Sarcoidosis

3. Cardiomyopathy, not tachycardia related

4. Coronary vascular malformation

5. Mitral valve prolapse

6. False tendon/moderator band

7. Non-compact myocardium

8. Atypical ventricular dysplasia pattern

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Perfusion Delayed Enhancement

Ventricular Tachycardia Ablation in the “Normal” Heart

Ventricular Tachycardia Ablation in the “Normal” Heart

• Outflow tract VT• Appreciating the relative anatomy• Clinical arrhythmia syndromes• Causes of difficulty with ablation

• Cuspal tachycardias• VT• Atrial arrhythmias • Accessories pathways

• Investigating potential structural causes• Dysplasia• Coronary malformations

• Remnant fascicles

• Outflow tract VT• Appreciating the relative anatomy• Clinical arrhythmia syndromes• Causes of difficulty with ablation

• Cuspal tachycardias• VT• Atrial arrhythmias • Accessories pathways

• Investigating potential structural causes• Dysplasia• Coronary malformations

• Remnant fascicles

Mapping and Ablation of Challenging Outflow Tract VTs:

Pulmonary Artery, LVOT, Epicardial

Mapping and Ablation of Challenging Outflow Tract VTs:

Pulmonary Artery, LVOT, Epicardial

Samuel J. Asirvatham, MDMayo Clinic Rochester

California Heart Rhythm SymposiumSan Francisco, CA

September 8, 2012 – 1:45 PM

Samuel J. Asirvatham, MDMayo Clinic Rochester

California Heart Rhythm SymposiumSan Francisco, CA

September 8, 2012 – 1:45 PM