9/18/2016

1

VT ablation: Who and When

2016 OSU Contemporary Multidisciplinary Cardiovascular Conference

Bradley P. Knight, MDDirector of Cardiac Electrophysiology

Northwestern University

bknight@nm.org

Case

• 66 y/o man with history of inferior MI 8 yrs ago• EF normal. No heart failure• Presents to ED with sustained MVT at 130 bpm• Cardioverted in ED and admitted• Cath shows chronically occluded mid RCA• Now what?

9/18/2016

2

EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm 2009

EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm 2009

9/18/2016

3

Case

• 66 y/o man with history of inferior MI 8 yrs ago• EF normal. No heart failure• Presents to ED with sustained MVT at 130 bpm• Cardioverted in ED and admitted• Cath shows chronically occluded mid RCA• Now what?• Catheter ablation procedure

Techniques Used to Identify Successful Target Sites for Ablation of VT in Patients with Prior MI

• VT morphology on 12-lead ECG• Infarct or aneurysm location• Endocardial activation time• Pace-mapping during SR• Concealed entrainment• Isolated middiastolic potential• Ratio of stimulus-QRS to VTCL• Stimulus-QRS and EGM-QRS

difference • Post-pacing interval

9/18/2016

4

Ablation of VT from Inferior Infarct

Ablation of VT from Inferior Infarct

9/18/2016

5

Case

• 66 y/o man with history of inferior MI 8 yrs ago• EF normal. No heart failure• Presents to ED with sustained MVT at 130 bpm• Cardioverted in ED and admitted• Cath shows chronically occluded mid RCA• Now what?• Catheter ablation procedure

• What if VT hemodynamically unstable?

9/18/2016

6

Approaches for Ablation of Hemodynamically Unstable

(or Unsustained) VT

• Substrate mapping using advanced mapping system

• Pace-mapping

• Noncontact mapping

• Vasopressors

• Percutaneous LVAD

• Slow VT (with Procainamide)

Case

• 66 y/o man with history of inferior MI 8 yrs ago• EF normal. No heart failure• Presents to ED with sustained MVT at 130 bpm• Cardioverted in ED and admitted• Cath shows chronically occluded mid RCA• Now what?• Catheter ablation procedure

• What if VT is epicardial?

9/18/2016

7

Case

• 66 y/o man with history of inferior MI 8 yrs ago• EF normal. No heart failure• Presents to ED with sustained MVT at 130 bpm• Cardioverted in ED and admitted• Cath shows chronically occluded mid RCA• Now what?• Catheter ablation procedure

• What if there is an LV thrombus?

9/18/2016

8

EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm 2009

Case

• 22 y/o woman referred for “bradycardia”• Found to have bigeminy• PVC burden on Holter 28%

9/18/2016

9

22 y/o Woman with Ventricular Bigeminy

Case

• 22 y/o woman referred for “bradycardia”• Found to have bigeminy• PVC burden on Holter 28%• Morphology RBIA, negative in I

• Echo/MRI EF 50%, mild LV dil. No scar• Failed trial of beta blockers

9/18/2016

10

EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm 2009

Figure 2. Sectional view at the base of the heart showing the important relation of the aortic valve with all other cardiac valves and myocardium.

Niloufar Tabatabaei, and Samuel J. Asirvatham Circ Arrhythm Electrophysiol. 2009;2:316-326

Copyright © American Heart Association, Inc. All rights reserved.

9/18/2016

11

PVC: ‐24 msec at AMC

9/18/2016

12

PVC From Near His Bundle

VT ablation: Who and When

• VT in patients with structural heart disease• CAD vs. Nonischemic CM patients• Initial presentation vs. multiple ICD therapies• Hemodynamically stable vs. not stable• Endocardial vs. epicardial approaches

• Idiopathic VT • RVOT VT• Left posterior fascicular VT

• Symptomatic or Frequent PVCs causing DCM

9/18/2016

13

VT ablation: Who and When

2016 OSU Contemporary Multidisciplinary Cardiovascular Conference

Bradley P. Knight, MDDirector of Cardiac Electrophysiology

Northwestern University

bknight@nm.org