Quando procedere all’ablazione della tachicardia ventricolare

rinunciando al defibrillatore

Leonardo Calo’

Direttore U.O.C. Cardiologia

Policlinico Casilino -Roma

DISCLOSURE INFORMATION

No conflict of interest

In 11 pts (group B; 35%), electroanatomic voltage mapping was normal.

Low-voltage areas in pts from group A corresponded to echocardiographic/angiographic RV wall motion abnormalities and were significantly associated with myocyte loss and fibrofatty replacement at biopsy (P < 0.0001) and familial ARVC/D (P < 0.0001).

“Border-zone”

I

Abld

I

Abld

I

Abld

Variable diastolic potentials at the site of successful ablation

Circulation 2006;114:32-39

An example of CMR in a 64-year-old male patient with an inferior MI (white arrows), preserved LV systolic function (LVEF, 61%), and normal LV systolic volume index. The MI of this pt was characterized by a substantial peri-infarct zone (yellow region) with a %MDE periphery measuring 27%. The patient died 11 months after undergoing the CMR examination.

TV1

TV2, 3

TV4, 5, 6

Ablazione del substrato

aritmogeno di TV, FE 15%, NYHA

III, ICD

Con isoproterenolo

22-years old male - No structural heart disease - Palpitations

* * *

TV IDIOPATICA DEL VENTRICOLO SN

A

B

* *

AO Adx

Vdx TE

Vsn

TV IDIOPATICA DEL TRATTO DI EFFLUSSO SN

Cuspide coronarica sn - Cuspide coronarica dx-

Setto interventricolare

Origin of outflow tract ventricular arrhythmia

Yamada, JACC 2008; 52(2), 139–147

About 70% of outflow tract VA are from RVOT, inferior to the PV

Catheter Ablation - Outcome

Aliot EM,et al.: EHRA/HRS Expert Consensus on Catheter ablation of VA. Europace 2009, 11:771–817

• Acute success rate typically > 90%

• Recurrences occur in about 5% of cases

• Complications during ablation of idiopathic VTs are rare

– mainly related to vascular access

– tamponade or perforation occur in < 1% of the cases • Long-term follow-ups and larger sample sizes are still missing

Tachycardia-Related Cardiomyopathy

• TCM is caused by very frequent runs of VT as well as PVCs

• The threshold of ectopy needed to result in TCM has been evaluated by many authors:

– Yarlagadda et al. PVC > 17,000 daily

– Takemoto et al. PVC > 20% daily

– Baman et al. PVC > 24% daily

– Hasdemir et al. PVC > 16% daily

– Niwano et al. PVC > 31,268 daily

• Thus, patients likely need to have > 10,000 PVCs daily over a substantial period (≈4 years) to cause TCM

• TCM is uncommon and occurred in 5-6% of patients

Eric N. Prystowsky et al. J Am Coll Cardiol 2012;59:1733–44

PVC-induced cardiomyopathy: mechanisms

Niwano et al Heart 2009

Cut point 20000/24h

PVCs number

Case 1

Ablation site

Pt 2 E.F. Male - 44 yrs

baseline Post RFA - 6 months

Case 2

Medical history

M.A. 59 years old female

Hypercholesterolemia; no other risk factors

Highly symptomatic for palpitations since several months

NYHA class II

Echo: Mitral valve prolapse with mild regurgitation; EF 46%; LVED 56 mm

On therapy with betablockers: persistence of symptoms

Holter: sinus rhythm; 34000 PVCs (two morphologies; one highly predominant); couplets; frequent runs of NSVT

Cardiac MRI LVEF 45%

No evidence of right vetricular delayed enhancement

Abl u

Abl

Endocardial signals at successful site

RF ablation

Parameters: 25 to 30 W and 43°; thermocool

Final ECG

Follow-up Bisoprolol was interrupted at 30 days follow-up

At 45 days follow up the patient is asymptomatic

24 hours Holter: normal sinus rhythm; 48 polymorfic PVCs

Echo: Slitght improvement of EF from 46% to 50% at 2 months

Case 3

Athlete 35 y.o. male caucasian with 15000 polymorphic PVC, isolated, 228 couplets, 15 NSVT 4 beats

Athlete 35 y.o. male caucasian with 15000 polymorphic PVC, isolated, 228 couplets, 15 NSVT 4 beats

MRI late enhancement inferior basal wall

Athlete 35 y.o. male caucasian with 15000 polymorphic PVC, isolated, 228 couplets, 15 NSVT 4 beats

Case 4

34 y.o. male caucasian with repetitive monomorphic NSVT No family history of heart disease

Symptomatic for palpitations, no syncope

34 y.o. male caucasian with repetitive monomorphic NSVT (GALLAVARDIN)

MRI: absence of cardiomyopathy

Holter monitoring:

27000 PVC, absence during sleep.

NSVT during Holter monitoring.

MRI absence of heart disease

EPS no inducibility of arrhythmias

No low voltage areas during electroanatomical mapping

Electrophysiological study:

mapping of right ventricular outflow tract (RVOT), inducibility of arrhythmias, RF ablation

Case 5

MRI absence of heart disease

EPS no inducibility of arrhythmias

No low voltage areas during

electroanatomical mapping