ischaemic ventricular tachycardia...•current vt ablation strategies appear to be beneficial in...

ISCHAEMIC VENTRICULAR TACHYCARDIAPRAPA KANAGARATNAM

IMPERIAL COLLEGE HEALTHCARE

AVID STUDY

AVID, NEJM 1997

QUALITY OF LIFE AFTER ICD SHOCKS

CIDS - QOL better for ICD than amiodarone but benefit was lost with shocks

(Irvine, Am Heart J 2002)

Mark, NEJM 2008

ICD OVERTREATMENT IN SECONDARY PREVENTION

Wathen, Am Heart J 2007

ICD overtreatment in primary prevention

Wathen, Am Heart J 2007

Kleeman, Europace 2015

ICD THERAPIES ARE ASSOCIATED WITH INCREASED MORTALITY

MEDICAL THERAPY TO PREVENT SHOCKS

OPTIC Study, JAMA 2006

STABLE VT CAN BE MAPPED BY ENTRAINMENT

Stevenson, Circulation 1993

STABLE VT CAN BE MAPPED BY ENTRAINMENT

Stevenson, Circulation 2008

APPROACHES TO SUBSTRATE ABLATION

Substrate Ablation Target Reference

Scar Homogenisation Di Biase, JACC 2012

Scar border-zone ablation Tilz, Europace 2014

Linear lesions Marchlinski, Circ 2000

Voltage gradient channels Arenal, Circ 2004

Pace map defined channels Nayyar, Circ AE 2014

VANISH STUDY

• MI and ICD

• Episode of VT during treatment with

amiodarone or another class I or class III

AAD within the previous 6 months.

• >3 ATP episodes , > 1 shock; >3 episodes

in 24hrs or VT below detection rate

Sapp NEJM 2016

VANISH STUDY

• Catheter Ablation vs Escalated Medical

Therapy

• Amiodarone 300mg/ Mexilitene

• Standardised programming

• Composite Endpoint of death, three or

more documented episodes of ventricular

tachycardia within 24 hours (ventricular

tachycardia storm), or appropriate ICD

shock.

Sapp NEJM 2016

VANISH STUDY

• Catheter Ablation vs Escalated Medical

Therapy

• Amiodarone 300mg/ Mexilitene

• Standardised programming

• Composite Endpoint of death, three or

more documented episodes of ventricular

tachycardia within 24 hours (ventricular

tachycardia storm), or appropriate ICD

shock.

VANISH STUDY

• Catheter Ablation vs Escalated Medical Therapy

• Amiodarone 300mg/ Mexilitene

• Standardised programming

• Composite Endpoint of death, three or more

documented episodes of ventricular tachycardia

within 24 hours (ventricular tachycardia storm), or

appropriate ICD shock.

VANISH STUDY

• Catheter Ablation vs Escalated Medical

Therapy

• Amiodarone 300mg/ Mexilitene

• Standardised programming

• Composite Endpoint of death, three or

more documented episodes of ventricular

tachycardia within 24 hours (ventricular

tachycardia storm), or appropriate ICD

shock.

VT-ABLATION STUDIES AND MORTALITY

VT-ABLATION STUDIES AND RECURRENT VT/THERAPY

VT ABLATION OUTCOMES BY EJECTION FRACTIONS

RIPPLE MAPPING IN THE VENTRICLE

ENTRANCE

EXIT

DETAILED ANALYSIS OF RIPPLE MAP SUGGESTS LOCATION OF CRITICAL ISTHMUS

Detailed analysis of Ripple map suggests location of critical

isthmus

Critical isthmus with varying conduction velocity

Inner loop/blind alley

Detailed analysis of Ripple map suggests location of critical

isthmus

Luther et al,

Circ Arrhyth

Electrophysiol 2016

Detailed analysis of Ripple map suggests location of critical

isthmus

Stevenson et al,

Circulation 1993

Luther et al,

Circ Arrhyth

Electrophysiol 2016

Critical isthmus with varying conduction

Inner loop/blind alley

CONDUCTION CHANNEL ABLATION USING RIPPLE MAPPING

CONDUCTION CHANNEL ABLATION USING RIPPLE MAPPING

ABLATING IN PATCH OF EARLIER LATE-POTENTIALS LEADS TOLOSS OF LATEST LATE-POTENTIALS

Pre-ablation

signal on

mapping catheter

Loss of late

potential after

ablation in earlier

potential

SUMMARY

• ICD therapies are associated with increased mortality

• Any ICD shock has major effect on quality of life

• Current VT ablation strategies appear to be beneficial in EF>30% patients

• Alternative endpoints/strategies needed to improve outcomes from VT ablation