Kammertachykardien: Wann abladieren? - Cardio Update 05/2021 - Patrick Badertscher
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Kammertachykardien: Wann abladieren? Cardio Update 05/2021 - Patrick Badertscher
77 jähriger Patient mit electrical storm Ischämische Kardiomyopathie, 3-GE, LVEF 25%, St. n. AKB KT im 11/2020, sekundärprophylaktisch VVI-ICD Seither unter Cordarone Hospitalisation im 04/2021, kardial dekompensiert, multiple ICD Schocks Verlegung ans USB, incessant KT, Tc um 140 bpm
77 jähriger Patient mit electrical storm
Lokalisation des Exits der VT?
77 jähriger Patient mit electrical storm
Herz MRI 11/2020
Scar-related ventricular tachycardia
Mechanism: Reentry
Substrate: regions with slow conduction and fixed or
functional conduction block
Channel /
Isthmus
Exit
Overview I. Observational Data II. Randomized Data III. Indications according to current guidelines IV.AAD versus Catheter ablation of VT V. Novel tools to improve outcomes
Prognostic Importance of Defibrillator Shocks in Patients
with Heart Failure
811 patients with primary prevention ICDs, median FU 46 months
Poole J et al, NEJM 2008The OPTIC Study
39%
• RCT: BB vs. Sotalol vs.
Amiodarone
24% • 412 Patients with ICD for
secondary prevention
• Discontinuation for any reason
18% for amiodarone and 24%
10% for sotalol
• 8 Hypo- or hyperthyrodism
(5.7%), 7 Pulmonary adverse
events (5.0%), 4 skin adverse
events (3%)
Connolly S et al, JAMA 2006The Multicenter Thermocool VT ablation Trial
Pre-Approval, n=231 Post-Approval, n=249
VT episodes reduced by 75% in 67% of patients VT episodes reduced by 50% in 64% of patients
Stevenson WG et al, Circulation 2008 Marschlinksi F et al, JACC 2016International VT Ablation Center Collaborative
Group study (IVCT)
• Largest study to date: 2061
patients, Scar related VT
• 12 centers
• 70% freedom from VT
recurrence, transplant, and
mortality at 1 year
• Patients referred for VT
ablation have a
transplant/mortality rate of
15% at 1 year
• lower EF, advanced NYHA,
and multiple VT morphologies
are associated with higher
recurrence rates
Tung R et al, Heart Rhythm Journal, 20155 randomized controlled trials (RCTs)
Vs. Vs.
SMASH VT BERLIN VT VANISH
NEJM 2007 Circ 2020 NEJM 2016
VTACH SMS
Lancet 2010 Circ A&E 2017SMASH VT trial
POST MI +
n = 128
*Patients were excluded if they were being treated with a class I or class III antiarrhythmic drug
Reddy V et al, NEJM, 2007SMASH VT trial
• Incidence of appropriate ICD
shocks decreased by 70%
(p=0.003)
• Conducted 2007
• «Single Operator»
• 2 yr success rate 88%
• 20% of patients ablated for VF
Reddy V et al, NEJM, 2007VTACH study
POST MI + LVEF < 50%
Vs.
n = 110
Kuck KH et al, Lancet, 2010VTACH study
• Incidence of appropriate ICD
shocks decreased by 46%
(p=0.045)
• Heterogenous benefit: No
differences when LVEF < 30%
• SMASH: same population,
different results, diffucult to
generalize and apply
Kuck KH et al, Lancet, 2010Vanish
n = 259
Sapp JL et al, NEJM, 2016Vanish
• Incidence of appropriate ICD
shocks decreased by 23%
(p=0.19)
• Not generazible to patients
that are Amio naive
• Triple endpoints: VT Storm,
Death and ICD shocks, p=ns
Sapp JL et al, NEJM, 2016Berlin VT Willems S et al, Circ, 2020
Berlin VT
Clinical implication:
In patients with ICM, LVEF
30%-50%, and documented
VT who are scheduled to
receive an ICD, VT ablation
should generally be
postponed until VT recurrence
after ICD implantation.Does VT ablation decrease mortality?
SMASH VT VANISH
NEJM 2007 NEJM 2016
VTACH SMS
Lancet 2010 Circ A&E 2017What about safety? Tung R et al, Heart Rhythm Journal, 2015
What about safety?
SMASH-VT, VTACH, SMS, VANISH, BERLIN VT
Incidence of proceudre related deaths – 0%
Incidence of major complications - 3.8% to 7.4%
VANISH
NEJM 2016 Vs.
3 deaths from amio in 127 patients 0 deaths in 132 patients
• 2 from pulmonary toxic effects • 2 cardiac perforations
• 1 death from hepatic dysfunction • 3 cases of major bleeding
Sapp JL et al, NEJM, 2016What about NICM? Titel/
Emergence of NICM Substrate Scar at any layer/depth
MRI–Derived Scar Patterns and Associated VT in NICM
2 typical scar patterns (anteroseptal and inferolateral) account for 89% of arrhythmogenic substrates in
patients with NICM
Piers S et al, Circ A&E, 2013VT ablation in NICM Kumar S et al, Heart Rhythm 2016;13:1957 Dinov B et al, Circulation 2014
Mixed Cardiomyopathy
Clues:
VT Morphology inconsistent with CAD distribution
Imaging abnormality inconsistent with/out of proportion to CAD distribution
• 723 consecutive patients referred for VT ablation
• Hx of myocardial infarction and angiography
documented CAD with presumed ischemic VT
• Ventricular scar inconsistent with CAD
distribution was found in 9 (1.2%) patients
Aldhoon et al, Heart Rhythm, 2013Data Summary RF ablation of VT in patients with structural heart disease has been shown to reduce recurrent VT/VF, ICD shocks, hospital readmission and quality of life RF ablation is the best treatment of patients with recurrent ICD shocks and failed AAD Only 1 RCT AAD versus CA, No RCT with AAD naive patients Mortality benefit has not been shown Safety: Incidence of major complications - < 5%
Indication catheter ablation in monorphic VT Priori SG et al, 2015 ESC Guidelines for VA and the prevention of SCD Cronin E et al, 2019 EHRA/HRS expert consensus statement on VA
Wann ist der optimale Zeitpunkt für eine KT Ablation?
77 jähriger Patient mit electrical storm
Ischämische Kardiomyopathie, 3-GE, LVEF 25%, St. n. AKB
1 KT im 11/2020, sekundärprophylaktisch VVI-ICD BERLIN VT
Circ 2020
Seither unter Cordarone
2 01/2021: Detektion einer VT 171/min welche mittels 9x ATP terminiert werden
konnte VANISH
NEJM 2016
Hospitalisation im 04/2021, kardial dekompensiert, multiple ICD Schocks
3
Verlegung ans USB, incessant KT, Tc um 140 bpmEarly vs. Late Referral for CA of VT
• Meta-Analysis
• 3 retrospective studies
• 980 patients
• Follow up 29 +/- 27 months
• Early: CA within 30 days after
first documented VT
• Late: failure of > 1 AAD to
control AAD
Romero J et al, JACC EP 2018AAD vs. Ablation
1 randomized study to date comparing the two strategies
Vs.
Not FDA approved for AF: “Off-label” • Procedural complications
Discontinuation • Challenging Procedures
• 20% in OPTIC over 1 year
• 32% in SCD-HEFT over 4 yrsThree aspects favoring ablation:
Amio
1) Procedural safety of CA can be improved
Ablation
2) Substrate mapping in SR facilitate procedure
3) Novel strategies to improve outcomes1) Safety of VT ablation can be improved by
1) Experience 2) Substrate Mapping in SR 3) Imaging
OR 0.69, P = .014
US Nationwide Database: 4653 procedures
Palaniswamy S et al, Heart Rhythm 2014 Marchlinski, Circulation, 2000; Di Biase, JACC, 2012; Berruezo, Circulation A&E, 2015;2) Substrate based ablation strategies
Reliably inducible, well tolerated single monomorphic VT is not the rule
Noninducibility
relation of the induced to the spontaneous VT remains uncertain.
Poor hemodynamic tolerance
Wie findet man das Substrat?2) Substrate based ablation strategies
Scar homogenization2 Substrate/core isolation5 Linear Ablation1
1Marchlinski, Circulation, 2000; 2Di Biase, JACC, 2012;
5 Tzou, Circulation A&E, 2015;2) Contemporary substrate based ablation
strategies
Late Potentials Abolition4 Dechanneling6
LAVA Elimination3
ILAM
1Marchlinski, Circulation, 2000; 2Di Biase, JACC, 2012;
3Jais,Circulation, 2012; 4Vergara & Della Bella, JCE, 2012; 621
5 Tzou, Circulation A&E, 2015; 6Berruezo, Circulation A&E, 2015;3) Novel strategies to improve outcomes
New Tools: Adjunctive Ablation Techniques Bipolar Ablation Half-Normal Saline Irrigant Needle Hybrid Surgical Alcohol Injection Stereotactc Radiation Beam Therapy
0,45% NaCl: Altering surrounding ionic content
Bipolar Ablation
Bipolar Ablation
Nguyen…Tzou, Sauer. Heart Rhythm 2016 and 2017Role of Imaging: Pre-procedural (CT/MRI)
• Accurate Anatomy of Cardiac Chambers
• Anatomical Landmarks for optimal
registration
• Structures at risk during epicardial
ablation (CA&PN)
• Comprehensive localisation of structural
substrate
• Structural substrate heterogeneityRole of Imaging: Pre-procedural (CT)
Ridges between thin scar = VT isthmus
Ghannam et al. JCE 2018Role of Imaging: Pre-procedural (CT)
Role of Imaging: Pre-procedural (CT)
Role of Imaging: Pre-procedural (CT)
Role of Imaging: Pre-procedural (CT)
Role of Imaging: Intra-procedural (ICE)
Role of Imaging: Intra-procedural
Role of Imaging: Intra-procedural
Conclusion I: Idiopathic PVC/VT Symptomatic treatment (exception: PVC-induced CMP) Most common type: Outflow-Tract PVC/VT Management with AAD (verapamil, class Ic) or ablation No ICD needed Ablation very effective (experienced centre, since 40% not from RVOT)
Badertscher P et al, JCE, 2021
Conclusion II: Ablation of scar-related VA In scar related VA with frequent ICD shocks catheter ablation is able to suppress recurrent Tc with a high success rate Ablation does not replace an ICD ! Indications for ablation Incessant VT, electrical storm (class I) Frequent ICD shocks (class I) Must be performed in experienced centres May be a «staged» procedure
Conclusion III: Ablation of scar-related VA Reentry is responsible for most VT in structural heart disease VT ablation has evolved in technique and improved in outcomes Mapping and substrate-based ablation Multi-disciplinary efforts Challenges remain in controlling VAs involving midmyocardial substrate Advances continue to be made
Report Card EP ablation
Supraventricular tachycardia: > 98%
• WPW syndrome
• AVNRT
Right atrial flutter: > 98%
Complex ablation
• PVC > 85%
• Paroxysmal AF > 80-90%
• Scar Ventricular Tc > 50-75%
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