Transcript of Ventricular tachycardia_lecture
- 1. Ventricular Tachycardia , Lin Yenn-Jiang MD. Chen Shih-Ann
MD. April 24, 2011 Advanced EP training, THRS St. Jude Medical,
TaipeiDivision of Cardiology, Taipei Veterans General Hospital and
National Yang-Ming University, Taipei, Taiwan
- 2. Experience of VT EPS/ABL in Taipei VGH 2000-2010Outflow
tract VT : 121 : 61%Fascicular VT : 24:12%ARVC :18: 9%CAD : 18:
9%DCM : 8: 4%
- 3. P=0.007Survival curve of VT patients (N=200) Fascicular VT
RVOT ARVC CPVT, idiopathic VF Ischemic VT DCM
- 4. How to Map VTMapping Basic electrophysiologic study Pace
mapping Activation mapping Electroanatomic mappingAblation: RV, LV,
and Epicardium
- 5. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT
- 6. Outflow Tract Ventricular Tachycardia (OT-VT)VT arises from
the right ventricular outflowtract (RVOT-VT, left ventricular
outflowtract (LVOT-VT), aortic cusps (Cusp VT),and from the
pulmonary artery (PA VT)OT-VT tend to occur in the absence
ofstructural heart disease and are focal inorigin, the 12-lead ECG
recorded duringVT is a precise localizing tool.
- 7. Clinical Features of RVOT-VTRVOT VT constitutes 75% of all
patientswith outflow tract VTRVOT VT is more common in females
30-50 years old.Symptoms include palpitations, dizziness,atypical
chest pain, and syncope.Exercise testing reproduces the
patientsclinical VT 25 to 50% of the time.
- 8. Mechanism of RVOT-VTMost forms of RVOT VT are sensitive
toadenosineMost likely mechanism is catecholaminemediated DAD and
triggered activity.Mediated by the activation of cyclic AMP.Can be
induced in the EP lab withisoproterenol, aminophylline, atropine,
andrapid burst pacing but rarely withprogrammed ventricular
extrastimuli.
- 9. 1. Important overlapping nature of the outflow tract
course!2. RVOT and PA lie anterior and to the left of the LVOT and
aorta.
- 10. RVOT VTIIIIIIaVRaVLaVFV1V2V3V4V5V6
- 11. RVOT VT morphology
- 12. Pulmonary Artery VT
- 13. How to D/D RVOT and VT with ASC in origin
- 14. Cross over of RVOT & LVOT region I: biphasic, V1 :W L R
I: positive L V1 :RS R AP view Superior view David Callans JCE
2009
- 15. Aortic Cusp VT Morphology
- 16. LVOT and Aortic Cuspid VTVT arising from the LVOT shares
similarcharacteristics to the RVOT VT because of acommon embryonic
origin.ECG: LBBB with inferior axis with small R-waves in V1 and
early precordial transition(R/S 1 by V2 or V3) or RBBB morphology
withinferior axis and S-wave in V6.Aortic cusp VT accounts for up
to 21% ofidiopathic VT.More commonly arises from the LCC, than
theRCC and rarely arise from the NCC.
- 17. Tabatabaei and Asirvatham. Circ EP 2009;2:316-326
- 18. LVOT VT Morphology
- 19. Mapping Tool for OT-VTECG morphology:Could be
non-induciblePacing morphologycould be large area 2 cm2: different
chamber, scar, orepicardium,Activation mapMore accurate: remain
unsuccess: more mapping sites,epicardium, different energy
sources,
- 20. Spontaneous PVC Pace Mapping Taipei VGH 2010
- 21. PVCDisappearanceJustAfterRF
- 22. Schema of the Ventricular Arrhythmia Origin, Breakout Site,
and Preferential Conduction From the LCC Origin to the RVOT or Left
Ventricular Septum T. Yamada, et al JACC, 2007, Vol. 50, No. 9:
884-91
- 23. DifficultyinPaceMappinginRVOTTWithScarA VT PM 1 PM 2 B RVOT
2 1 Septal wall Anterior wall Free wall Taipei VGH 2010
- 24. Requirement of NCM for VT mappingPacing mapping may not
sensitive tolocate the sites of foci in certain patientswith focal
VT, in the presence of largescar area.VT could be non-sustained and
unstable.It is difficult to map the entire chamberOne beat analysis
of dynamic substrate byNCM may be useful to treat these
patients.
- 25. EnsiteArrayLocation Taipei VGH 2010
- 26. RVOT VPC form the LVZ border(Higa S: University of the
Ryukyus, Okinawa, Japan) 2010 Taipei VGH
- 27. Conclusions Carefully ECG interpretation and EP study to
localize the optimum ablation site for VT. Usually not life
threatening, and could be treated conservatively. 3D mapping system
can be helpful (activation map or substrate map), but correct
chamber, far- field sensing, preferential conduction need to be
considered.
- 28. OutlinesOutflow tract VTRV related VT and ARVCFascicular
VTSubstrate VT
- 29. RVOT VTIIIIIIaVRaVLaVFV1V2V3V4V5V6
- 30. Idiopathic RVOT-TRight ventricular outflow tract
tachycardia(RVOT-T) represents up to 10% of all
ventriculartachycardias (VTs), and is considered as abenign
disease.Symptoms: Ranging from none to
palpitations,lightheadedness, dyspnea, or syncope.Arrhythmias:
Frequent isolated PVCs, bursts ofnonsustained VT, or sustained
tachycardia oftenfacilitated by catecholamines or
exercise.Ablation: Acute success rate of focal ablation ofRVOT-T is
6597% with rare complications.
- 31. ARVC
- 32. Arrhythmogenic RV DysplasiaCardiomyopathy begins in RV with
poor contractilefunction and dilatation, progresses to LV
finally.Histology: RV muscle becomes replaced by adiposeand fibrous
tissue.Arrhythmia: Re-entrant Type (scarring & latePotentials)
with LBBB type ECG;ECG: Diffuse T wave inversion over precordial
leads,and Epsilon Wave.Ablation: The effect of catheter ablation
istemporizing, 1/3 epicardium, mostly reentry.Implanted
cardioverter defibrillator (ICD) is the onlyreliable therapy for
sudden cardiac death.
- 33. Task Force Criteria TF(Definite+)
ifmeet2majoror1major2minorcriteria McKenna et al. 1994, BMJ
- 34. Long-term OutcomeMean follow-up period 23 28 months (0.3
127) Cumulative Incidence Cumulative Incidence TF (-), 3.1% TF (-)
: 14% TF (+) , 7.4% TF (+): 36%: P=0.511 P=0.019 Follow-Up Duration
Follow-Up Duration All Cause Malignant Mortality arrhythmias
- 35. Conclusions Positive TF criteria is important to diagnose
ARVC/D and is specific to detect the future VF/ICD implantation/ CV
mortality Malignant ventricular arrhythmia and late recurrences may
occur in patients with mild or atypical form of arrhythmogenic RV
cardiomyopathy.
- 36. Posterior Fascicular VT
- 37. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT
- 38. Diastolic potential & Purkinje potential
- 39. Posterior Fascicular VT
- 40. Where to TargetDiastolic potential (P1) in themidseptum of
LV. P1-QRS=28-130 msecIf P1 could not be identified, target
thefused and earliest Purkinje potential(P2)Successful ablation
revealed P1 duringSR could be a marker of successfulablation.
- 41. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT
- 42. Structure heart related VT BBRT Ischemic heart disease
(most common): mostly Endocardium ARVC: Epi/Endo Non-ischemic
cardiomyopathy: Epi/Edno Tetralogy of Fallot and other post
operation patients: Endo
- 43. Substrate VTIdentification of the critical ventricleto be
targeted (voltage mapping).Identify the location of the
scar(bipolar voltage 2 mV, < 70 msec, amplitude/duration70%
30-70% 40 msec: isthmus Entrainment mapping: Concealed entrain,
with PPI=TCL Outer loop vs. inner loop Critical isthmus, > 40
msec, < 70% of S-QRS, > 22% of S-QRS interval Substrate
mapping: Scar mapping
- 49. Case 1 Ventricular Tachycardia RV ICD Lead Pacing
- 50. Bi-Ventricular Voltage Map LVZ LVZ LVZ Ablation site Lin YJ
et al. HRS abstract 2009
- 51. Ischemic LV VT---Case 1The important to identify chamber to
ablate RVOT Septum LV apex ICD Lead Lin YJ et al. HRS abstract
2009
- 52. Lin YJ et al. HRS abstract 2009
- 53. IschemicLVVTCase2TheimportanttoidentifytheLVZandexitsite
Tsai WC et al. JCE in revision, 2010
- 54. Case:IschemicLVVTTheimportanttoidentifytheLVZandexitsite
Abnormal Substrate Entrainment Exit, entrance site Diastolic
potential Tsai and Chen, Circ J, 2011
- 55. Voltage Map during SR (DSM 30%) Taipei VGH 2010
- 56. RVOT-T Patient Voltage of SR Spectral Analysis Activation
of VT 3.5 cm from PV Successful site septum Free wall Eg during
SRScar in the free wall site
- 57. ConclusionsOutflow tract VT is the commonest form
ofidiopathic VT.ECG morphology is important for localization
offocal VT and exit site of substrate VT before 3 Dmapping.Pacing
mapping may not sensitive to locate thesites of foci in certain
patients with focal VT, inthe presence of large scar area.Substrate
mapping and entrainment mappingare important for the substrate
VT.