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Usefulness of new imaging techniques to identify complex arrhytmogenic
substrates in the ventricle
Venice Arrhythmias 2013“SOLAECE Corner”
Gerardo Rodríguez Diez MDNational Medical Center “20 de Noviembre”
ISSSTE. México D.F.SOLAECE Treasurer
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NO CONFLICT OF INTEREST TO
DECLARE
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Key points
o Backgroundo Ablation targetso New imaging techniques
• ICE• ce-CMR
o Conclusion
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Background
o Non structural heart disease (focal origin)• Increase Automaticity• Triggered activity (early or delayed
afterdepolarizations)
o Structural Heart disease (scar-related)• Ischemic or no Ischemic• Relative large reentry circuits• Complex substrates around the fibrosis
scars or border zones
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Pogwizd SM, et al. Circulation 1998. *Stevenson WG, Heart Rhythm 2013.
Ventricular Arrhythmias and Scar
• Critical anatomic substrates sustaining VA’s, shows different degrees of fibrosis / scar (even in cases of focal origin)
*90% of sustained VT’s are due to reentry involving an area of ventricular scar.10% remaining are due to reentry or automaticity involving the Purkinje system.
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Targets for ablationo Conduction channels (CC’s)
• Bundles of viable myocardium inside scars that become part of reentrant circuit during VT
• Are located at any level of the myocardium wall with variable thickness and a 3D- structure
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VT ablation targetso Electroanatomic maps (EAM)
• Is a depiction of cardiac anatomy (through a color-coded display of the intracardiac electrogam)
• Areas of interest• reduce electrogram amplitude in voltage mapso Normal Electrogram
amplitude• >1.5mVo Border zone electrogram• 0.5-1.5 mVo Core scar• < 0.5 mV
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Catheter Ablation of reentrant VT
o Goal: Identification of critical isthmus of conduction that is part of the reentrant circuit
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Conventional VT ablation limitations
o Hemodynamic intoleranceo Multiple changing morphologieso Hemodynamic collapseo Noninducible VT during EP testingo Recurrences (50-88%)o Identification of the underlying
substrate using voltage mapping with 3D reconstruction point by point• It’s cumbersome• Requires considerable skill• It’s time consuming
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Complex imaging techniques
o Rationale• Characterization of arrhythmogenic substrates• Direct guidance and characterization of ablation
lesions• Early detection or prevention of procedural
complications• Earn time during procedure
o Imaging techniques are for defining the anatomyo Intracardiac echocardiography (ICE)• Accurate to describing the anatomy
o Contrast enhanced cardiac magnetic resonance (ce-CMR)
• Accurate to identify CC’s into the core scar
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Ablation with ICEo Allow us to watch the ablation tipo Identification of anatomic structures
• Coronary cuspids• Papillary Muscle• Akinetic and Scar zones
o Allow us to identify early complications during the procedure
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Image ablation with ICE
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Epicardial Ablation with ICE
Bala et al. Cir Arrhythm Electrophysiol. 2011
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ICE mapping
o What we can´t do with ICE?• Identification of conduccion channels in
Scar and Border zones
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ce-CMR
o Predictive value for ventricular arrhythmia • Inducibility • Mortality
o Scar tissue characterization• Quantification• Heterogeneity
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Non-invasive Assessment of Cardiac Fibrosis
• Ce-Cardiac Magnetic Resonance• Prognostic value for arrhythmia inducibility and mortality• Scar tissue characterization (quantification / heterogeneity)
Infarct Core
Border Zone
Normal myocardium
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Quantitative/qualitative estimation of Cardiac Fibrosis
High SCD risk patients Low SCD risk patients
LVEF 35%
LVEF 35%
LVEF 35%
LVEF 35%
Fernández-Armenta J, Berruezo A, et al. Europace 2012.
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Image processing
Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
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Scar-Anatomy and 3D Structure of Scar-Anatomy and 3D Structure of Conducting ChannelsConducting Channels
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Anatomy and Scar IntegrationAnatomy and Scar Integration
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Scar - Anatomy and 3D Structure of Scar - Anatomy and 3D Structure of Conducting ChannelsConducting Channels
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Signal Intensity Maps
o Myocardial wall thickness 10% and 25%• Border zone
channel is suggested
• Sequential activation of electrograms
Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
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Identification of Conduction channels
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Endo and Epicardial maps
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Signal Intensity maps (SI)
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Limitations of ce-CMRo Image aquisition
• The partial volume effect• The presence of ventricular arrhytmias• Lack of adequate apneas• Variability of gadolinium kinetics
o Identification of channels in EAM is manual• CC branching with a trajectory hard to
define
o This technique larger and prospective studies
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cc-CMR guided ablation
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Summary
• Continuous improvement in cardiac imaging for arrhythmias in last years– Diagnosis and risk stratification
– Guiding interventions
– Saving time and be more accurate
• Evolution from gross anatomy to histology and function
• Need for cooperation between cardiac imaging specialist and electrophisiologist