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Ventricular tachycardia_lecture

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Ventricular tachycardia_lecture

  1. 1. Ventricular Tachycardia 林彥璋 醫師, Lin Yenn-Jiang MD. Chen Shih-Ann MD. April 24, 2011 Advanced EP training, THRS St. Jude Medical, TaipeiDivision of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
  2. 2. Experience of VT EPS/ABL in Taipei VGH 2000-2010Outflow tract VT : 121 : 61%Fascicular VT : 24:12%ARVC :18: 9%CAD : 18: 9%DCM : 8: 4%
  3. 3. P=0.007Survival curve of VT patients (N=200) Fascicular VT RVOT ARVC CPVT, idiopathic VF Ischemic VT DCM
  4. 4. How to Map VTMapping Basic electrophysiologic study Pace mapping Activation mapping Electroanatomic mappingAblation: RV, LV, and Epicardium
  5. 5. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT
  6. 6. Outflow Tract Ventricular Tachycardia (OT-VT)VT arises from the right ventricular outflowtract (RVOT-VT, left ventricular outflowtract (LVOT-VT), aortic cusps (Cusp VT),and from the pulmonary artery (PA VT)OT-VT tend to occur in the absence ofstructural heart disease and are focal inorigin, the 12-lead ECG recorded duringVT is a precise localizing tool.
  7. 7. Clinical Features of RVOT-VTRVOT VT constitutes 75% of all patientswith outflow tract VTRVOT VT is more common in females 30-50 years old.Symptoms include palpitations, dizziness,atypical chest pain, and syncope.Exercise testing reproduces the patient’sclinical VT 25 to 50% of the time.
  8. 8. Mechanism of RVOT-VTMost forms of RVOT VT are sensitive toadenosineMost likely mechanism is catecholaminemediated DAD and triggered activity.Mediated by the activation of cyclic AMP.Can be induced in the EP lab withisoproterenol, aminophylline, atropine, andrapid burst pacing but rarely withprogrammed ventricular extrastimuli.
  9. 9. 1. Important overlapping nature of the outflow tract course!2. RVOT and PA lie anterior and to the left of the LVOT and aorta.
  10. 10. RVOT VTIIIIIIaVRaVLaVFV1V2V3V4V5V6
  11. 11. RVOT VT morphology
  12. 12. Pulmonary Artery VT
  13. 13. How to D/D RVOT and VT with ASC in origin
  14. 14. Cross over of RVOT & LVOT region I: biphasic, V1 :W L R I: positive L V1 :RS R AP view Superior view David Callans JCE 2009
  15. 15. Aortic Cusp VT Morphology
  16. 16. LVOT and Aortic Cuspid VTVT arising from the LVOT shares similarcharacteristics to the RVOT VT because of acommon 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 withinferior axis and S-wave in V6.Aortic cusp VT accounts for up to 21% ofidiopathic VT.More commonly arises from the LCC, than theRCC and rarely arise from the NCC.
  17. 17. Tabatabaei and Asirvatham. Circ EP 2009;2:316-326
  18. 18. LVOT VT Morphology
  19. 19. Mapping Tool for OT-VTECG morphology:Could be non-induciblePacing morphologycould be large area 2 cm2: different chamber, scar, orepicardium,Activation mapMore accurate: remain unsuccess: more mapping sites,epicardium, different energy sources,
  20. 20. Spontaneous PVC Pace Mapping Taipei VGH 2010
  21. 21. PVC Disappearance Just After RF 
  22. 22. Schema of the Ventricular Arrhythmia Origin, Breakout Site, and Preferential Conduction From the LCC Origin to the RVOT or Left Ventricular Septum T. Yamada, et al JACC, 2007, Vol. 50, No. 9: 884-91
  23. 23. Difficulty in Pace Mapping in RVOT‐T With ScarA VT PM 1 PM 2 B RVOT 2 1 Septal wall Anterior wall Free wall Taipei VGH 2010
  24. 24. Requirement of NCM for VT mappingPacing mapping may not sensitive tolocate the sites of foci in certain patientswith focal VT, in the presence of largescar area.VT could be non-sustained and unstable.It is difficult to map the entire chamberOne beat analysis of dynamic substrate byNCM may be useful to treat these patients.
  25. 25. Ensite Array LocationRAO LAO Taipei VGH 2010
  26. 26. RVOT VPC form the LVZ border(Higa S: University of the Ryukyus, Okinawa, Japan) 2010 Taipei VGH
  27. 27. Conclusions 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.
  28. 28. OutlinesOutflow tract VTRV related VT and ARVCFascicular VTSubstrate VT
  29. 29. RVOT VTIIIIIIaVRaVLaVFV1V2V3V4V5V6
  30. 30. Idiopathic RVOT-TRight ventricular outflow tract tachycardia(RVOT-T) represents up to 10% of all ventriculartachycardias (VTs), and is considered as abenign disease.Symptoms: Ranging from none to palpitations,lightheadedness, dyspnea, or syncope.Arrhythmias: Frequent isolated PVCs, bursts ofnonsustained VT, or sustained tachycardia oftenfacilitated by catecholamines or exercise.Ablation: Acute success rate of focal ablation ofRVOT-T is 65–97% with rare complications.
  31. 31. ARVC
  32. 32. Arrhythmogenic RV DysplasiaCardiomyopathy begins in RV with poor contractilefunction and dilatation, progresses to LV finally.Histology: RV muscle becomes replaced by adiposeand fibrous tissue.Arrhythmia: Re-entrant Type (scarring & latePotentials) with LBBB type ECG;ECG: Diffuse T wave inversion over precordial leads,and Epsilon Wave.Ablation: The effect of catheter ablation istemporizing, 1/3 epicardium, mostly reentry.Implanted cardioverter defibrillator (ICD) is the onlyreliable therapy for sudden cardiac death.
  33. 33. Task Force Criteria TF (Definite +) if  meet 2 major or 1 major 2 minor criteria McKenna et al. 1994, BMJ
  34. 34. Long-term OutcomeMean follow-up period 23 ± 28 months (0.3 – 127) 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
  35. 35. Conclusions 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.
  36. 36. Posterior Fascicular VT
  37. 37. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT
  38. 38. Diastolic potential & Purkinje potential
  39. 39. Posterior Fascicular VT
  40. 40. Where to TargetDiastolic potential (P1) in themidseptum of LV. P1-QRS=28-130 msecIf P1 could not be identified, target thefused and earliest Purkinje potential(P2)Successful ablation revealed P1 duringSR could be a marker of successfulablation.
  41. 41. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT
  42. 42. Structure heart related VT• BBRT• Ischemic heart disease (most common): mostly Endocardium• ARVC: Epi/Endo• Non-ischemic cardiomyopathy: Epi/Edno• Tetralogy of Fallot and other post operation patients: Endo
  43. 43. Substrate VTIdentification of the critical ventricleto be targeted (voltage mapping).Identify the location of the scar(bipolar voltage <0.5 mV, unipolarPNV < 30%).Conventional entrainmenttechniques remain important.
  44. 44. Normal ElectrogramBipolar Eg: < 3 deflection, > 2 mV, < 70 msec, amplitude/duration<0.05
  45. 45. Bystander Outer loop
  46. 46. Isthmus
  47. 47. Successful ablation site• Abnormal site: LVZ, pre-systolic potential, fractionated electrograms Pacing during VT• Concealed entrainment.• Critical isthmus: with – 30-70% of the critical isthmus Concealed Fusion (S-QRS) – Diastolic potentials PPI=TCL S-QRS/TCL PPI not =TCL PPI=TCL >70% 30-70% <30% Bystander Outer loop Critical isthmus Inner loop Exit or outer loop
  48. 48. Mapping of Ventricular Tachycardia Out-loop• Activation mapping:• Pacing mapping Inner-loop – For focal VT – For substrate VT: near the exit site – S-QRS > 40 msec: isthmus• Entrainment mapping: – Concealed entrain, with PPI=TCL – Outer loop vs. inner loop – Critical isthmus, > 40 msec, < 70% of S-QRS, > 22% of S-QRS interval• Substrate mapping: Scar mapping
  49. 49. Case 1 Ventricular Tachycardia RV ICD Lead Pacing
  50. 50. Bi-Ventricular Voltage Map LVZ LVZ LVZ Ablation site Lin YJ et al. HRS abstract 2009
  51. 51. Ischemic LV VT---Case 1The important to identify chamber to ablate RVOT Septum LV apex ICD Lead Lin YJ et al. HRS abstract 2009
  52. 52. Lin YJ et al. HRS abstract 2009
  53. 53. Ischemic LV VT‐‐‐Case 2The important to identify the LVZ and exit site Tsai WC et al. JCE in revision, 2010
  54. 54. Case: Ischemic LV VT The important to identify the LVZ and exit site Abnormal Substrate Entrainment Exit, entrance site Diastolic potential Tsai and Chen, Circ J, 2011
  55. 55. Voltage Map during SR (DSM 30%) Taipei VGH 2010
  56. 56. RVOT-T Patient Voltage of SR Spectral Analysis Activation of VT 3.5 cm from PV Successful site septum Free wall Eg during SRScar in the free wall site
  57. 57. ConclusionsOutflow tract VT is the commonest form ofidiopathic VT.ECG morphology is important for localization offocal VT and exit site of substrate VT before 3 Dmapping.Pacing mapping may not sensitive to locate thesites of foci in certain patients with focal VT, inthe presence of large scar area.Substrate mapping and entrainment mappingare important for the substrate VT.

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