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