ablation strategy for ventricular arrhythmia storm in ischemic …k-hrs.org/khrs/2018/pdf/14. haris...

Ablation Strategy for Ventricular Arrhythmia

Storm in Ischemic Cardiomyopathy

Haris M. HaqqaniMBBS(Hons) PhD FRACP FCSANZ FHRS FACC

Associate Professor of Medicine, The University of Queensland

Senior Consultant Electrophysiologist, The Prince Charles Hospital

Brisbane, Australia

Disclosures

Company Name Relationship

Biosense Webster Research grant

Speaking honoraria

Boston Scientific Scientific advisory board

Speaking honoraria

Medtronic Scientific advisory board

Speaking honoraria

Abbott Speaking honoraria

The presenter has received financial support from the

organizations identified below for the relationships listed:

KHRS Scientific Sessions 2018, Seoul8 June 2018 2

8 June 2018 KHRS Scientific Sessions 2018, Seoul 3

Ablation strategies for

electrical storm in ICM

Ablation of inducible VTs

(+/- MCS)

Substrate ablation in

SR (+/- MCS)

Renal denervation by

catheter ablation

Ablation of scar border zone PVC

triggers of VT

Ablation of PVC triggers

of PVT/VF

Neuraxial

autonomic

modulation

Issue #1: Heterogeneity in the

definition of electrical storm


Commonest definition:

Three or more separate episodes of VA

requiring intervention (usually ICD

therapy) within a 24 hour period

Sagone. J Atr Fib. 2015

Issue #2: Variability in the

clinical presentation within

this definition


Patient 1:

64yo male with ICM, LVEF 32%

Develops sudden dyspnea

Sustains two ICD shocks at home

Two further shocks in ambulance on

12 episodes of ATP terminated

SMVT in 3 days

4 accelerated to PMVT CV

No further VA on amio/lignocaine


clinical presentation within

this definition


Patient 2:

51yo man with ICM, LVEF 38%

Collapses at auction

13 ICD shocks over 20 mins

Initial 3 due to rapid SMVT

Subsequent shocks due to PVT

Ongoing episodes in CCU

despite amio/lignocaine


ventricular arrhythmia

responsible for the storm

8 June 2018 KHRS Scientific Sessions 2018, Seoul 7Sagone. J Atr Fib. 2015

8 June 2018 KHRS Scientific Sessions 2018, Seoul 8Nayyer et. al. EHJ. 2013


ventricular arrhythmia

responsible for the storm

Mechanism:

• Scar-related re-entry most common

mechanism 83% pts

• Purkinje-related or myocardial PVC

present in 14%

• Macroreentry within the His-Purkinje

system responsible for 3%

Case

• 41 year old man, smoker

• Type A personality ++, accountant

• presented late with inferior MI

• cath:


Case

• LVEF 33% at that stage, inferolateral hypokinesis

• CABG x3: LIMALAD, SVGPDA, SVGM1

• uncomplicated recovery apart from significant

bibasal atelectasis

• about to be discharged late on day 8…


• > 50 sustained episodes, most terminated by coughing; incessant non-sustained episodes

• 14 external shocks required initially

• ongoing episodes in ICU despite esmolol, lidocaine, amiodarone, midazolam and intubation with general anesthesia

• ECMO pump being primed ….

Case


I

II

III

aVR

aVL

aVF

V1

V6


I

II

III

aVR

aVL

aVF

V1

V6

EP lab at

midnight


I

II

III

aVR

aVL

aVF

V1

V6

Multiple

DCCV

required


On postero-

medial papillary

muscle


I

II

III

aVR

aVL

aVF

V1

V6

Pacemap

from PPM


I

II

III

aVR

aVL

aVF

V1

V6

MAPd

MAPp

Fragmented

Purkinje-like

potentials

on PPM


I

II

III

aVR

aVL

aVF

V1

V6

MAPd

MAPp

Earlier at

more SR

fractionated

sites on

PPM


I

II

III

aVR

aVL

aVF

V1

V6

MAPd

MAPp

Very early

fractionated

potentials

on PPM


I

II

III

aVR

aVL

aVF

V1

V6

MAPd

MAPp


I

II

III

aVR

aVL

aVF

V1

V6

MAPd

MAPp

No inducible

VT / VF with

aggressive

PVS at case

end


Follow-up

• ICD inserted pre-discharge

• No ICD events over 6 years

• No significant ectopy on PVC counters

• LVEF 50% on medical therapy

• No significant mitral regurgitation on

follow-up echocardiograms


Surviving myocytes/Purkinje

within non-uniform scar

Inhomogeneous

slowed conduction

Conducting

channels in scar

Reentrant VT

Substrate for

scar-related VT

Waller et. al. AJC 1998

De Bakker JMT. Heart Rhythm 2005

Stevenson W. HRS 20058 June 2018 KHRS Scientific Sessions 2018, Seoul 30

Channel / Isthmus

ExitOuter Loop

Entrance

Bystander

RF

RF

Courtesy of

Dr W Stevenson


>1.5 mV

<0.5 mV

I

II

III

aVR

aVL

aVF

V1

V6

68yo man

ICM, EF 20%

ICD shocks

apex

base

RAO8 June 2018 KHRS Scientific Sessions 2018, Seoul 32

Entrainment mapping

I

II

III

aVR

aVL

aVF

V1

V6

MAPd

MAPp


Early termination with RF ablation

I

II

III

aVR

aVL

aVF

V1

V6

MAPd

MAPp


8 June 2018 KHRS Scientific Sessions 2018, Seoul 35Ahn J, … Kim YH. et. al. KCJ. 2018

8 June 2018 KHRS Scientific Sessions 2018, Seoul 36Baratto et. al. Circ AE 2016

8 June 2018 KHRS Scientific Sessions 2018, Seoul 39Turagam et. al. JACC EP 2017

8 June 2018 KHRS Scientific Sessions 2018, Seoul 40Muser et. al. WJC. 2017

Marchlinski FE et. al. Circ 2000

Substrate

mapping &

ablation

>1.5 mV

<0.5 mV



Substrate ablation

strategies in ICM

Electrogram guided; ILP,

LAVA

Pacemapguided, long

S-QRS

Scar dechanneling

Core isolation

Scar homogenization

>1.5 mV

<0.5 mV


>1.5 mV

<0.5 mV


Final lesion set


Outcomes

Nayyer et. al. EHJ. 2013

• High procedural success rates:

72% no inducible VT

91% no inducible clinical VT

• Multiple procedures required in 19% (1.3 / pt)

• Low complication rate:

procedural mortality 0.6%

2% MI, tamponade, stroke, CHB

• VA recurrence rate 28% over 61 week f/u

higher recurrence with SMVT vs. PVT

94% freedom from VA storm

• 78 deaths (17%): 62% form

8 June 2018 KHRS Scientific Sessions 2018, Seoul 46Muser et. al. WJC. 2017

8 June 2018 KHRS Scientific Sessions 2018, Seoul 47Kumar et. al. JCE. 2017

8 June 2018 KHRS Scientific Sessions 2018, Seoul 48Kumar et. al. JCE. 2017

8 June 2018 KHRS Scientific Sessions 2018, Seoul 49Muser et. al. JACC EP. 2017

8 June 2018 KHRS Scientific Sessions 2018, Seoul 54Vergara et. al. HRJ. 2018

8 June 2018 KHRS Scientific Sessions 2018, Seoul 55Vergara et. al. HRJ. 2018

Conclusions

• Electrical storm in ischemic cardiomyopathy is a

heterogenous but concerning condition

• The ablation strategy chosen depends significantly on

the mode of presentation, degree of hemodynamic

effect and type of ventricular arrhythmia

• Mechanical circulatory support may be required

• Catheter ablation patients have low observed rates of

recurrent electrical storm

• Catheter ablation is associated with increased survival


ablation strategy for ventricular arrhythmia storm in ischemic …k-hrs.org/khrs/2018/pdf/14. haris...

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