2006 bologna, caso clinico. ablazione transcatetere di tachicardia atriale incisionale

INCISIONAL INCISIONAL LEFT ATRIAL TACHYCARDIALEFT ATRIAL TACHYCARDIA

(case report) (case report)

Stefano Nardi, MD

AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNIDIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE

STRUTTURA COMPLESSA DI CARDIOLOGIASTRUTTURA COMPLESSA DI CARDIOLOGIASTRUTTURA SEMPLICE DI ARITMOLOGIA STRUTTURA SEMPLICE DI ARITMOLOGIA

LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE

Incisional Left Atrial Incisional Left Atrial TachycardiaTachycardia

NavXTM System (ESI, St. Jude Medical) represents a novel MAPPINGMAPPING and NAVIGATIONNAVIGATION system that allows the possibility to create a 3D geometry of the heart, valves and vessels, using cutaneous patches, and moreover to visualize up to 12 conventional cardiac catheters

INTRODUCTIONINTRODUCTION


END-POINT END-POINT

• RECONSTRUCTION RECONSTRUCTION of a surface model of of a surface model of the LA endocardium the LA endocardium • IDENTIFIED IDENTIFIED the operative mechanism of the operative mechanism of AT AT • DESCRIBEDESCRIBE the EA characteristics the EA characteristics

• ASSESSASSESS the effect of RF lesion at the the effect of RF lesion at the identified target siteidentified target site


• 56 years-old men with previous MITRAL MITRAL VALVEVALVE replacement with prosthetic valve (rheumatic valvular disease)• SIX MONTH LATERSIX MONTH LATER cardiopalm, first paroxysmal then permanent.• The ECGECG surface reveals an AT with stable CL• Previously TWO INEFFECTIVE ECV.TWO INEFFECTIVE ECV. • AT duration was 12 months, despite using three different AADsAADs (Sotalol, Flecainide and Amiodaron) alone or with class IV

METHODSMETHODS


• Symptomatic for progressive DYSPNEADYSPNEA, with reducing TOLERANCETOLERANCE to the EFFORTEFFORT, and with a progressive DETERIORATIONDETERIORATION of

QOLQOL and NYHANYHA class (III).

• The TTETTE analysis reveals a LALA enlargement with LVLV dysfunction (LA size at TTE was 50 mm and LVEF ≈35%).

METHODSMETHODS


• INCESSANT AT INCESSANT AT with stable CL (320 ms)

• POSITIVE POSITIVE P wave in V1

• P wave, in the inferior limbs, DIFFERENT DIFFERENT from typical AFl

ECG DATAECG DATA

Incisional Left Atrial Incisional Left Atrial TachycardiaTachycardia• OCTAPOLAROCTAPOLAR catheter in the CS (reference

NavX)

• OCTAPOLAROCTAPOLAR catheter at the His bundle/RBB

• 20-polar CIRCULAR CIRCULAR mapping catheter into

the RA

• LONG SHEETLONG SHEET inserted into the RA

• Transeptal catheterization with BRKBRK needle

• An irrigated tip IRVINE (SJM)IRVINE (SJM) catheter into

LA.

SETTINGSETTING


• Both BIPOLAR BIPOLAR and UNIPOLARUNIPOLAR signal EGM were filtered at bandpass settings of 30 to 500 Hz and 0.05 to 200 Hz, and were digitally recorded.

• Systemic IV ANTICOAGULATIONANTICOAGULATION was starting with heparin-Na+ after transeptal puncture

• ANGIOGRAMANGIOGRAM of the PVs, was performed in two different axis (LAO/RAO), before mapping

• ACTACT was mantaining between 250 and 300s.

SETTINGSETTING

Incisional Left Atrial Incisional Left Atrial TachycardiaTachycardiaMAPPINGMAPPING


MAPPINGMAPPING


• VIRTUAL GEOMETRYVIRTUAL GEOMETRY correlate closely with ANATOMIC model, EP recordings and FLUOROSCOPIC images

• ILATILAT defined as continuous sequence of LA activation with earliest activation adjacent to latest activation.

• FRACTIONEDFRACTIONED and

DOUBLE DOUBLE POTENTIALSPOTENTIALS at the roof and posterior wall of the LA (left atriotomy)

• ENTRAINMENT ENTRAINMENT PACINGPACING at the target site reveal a “ “CONCEALED FUSION”CONCEALED FUSION”

MAPPINGMAPPING


• PULSESPULSES of RFRF (rose dots) were applied in order to create a block-line at the “target” site.• CURRENT DELIVERY CURRENT DELIVERY started at 20 W power and gradually increased (continuous monitoring of impedance, temperature, EGM) • RFRF was maintained until the bipolar atrial potential recorded decreased by 80% or split into double potentials (conduction block).

ABLATIONABLATION

Incisional Left Atrial Incisional Left Atrial TachycardiaTachycardiaCURRENT DELIVERYCURRENT DELIVERY was terminated if:

• DISAPPEARINGDISAPPEARING of LA potential

• FAILUREFAILURE to reach end-point after 120 s • Suddenly IMPEDANCE RISEIMPEDANCE RISE


ABLATIONABLATION

• The OPERATIVE OPERATIVE MECHANISM MECHANISM of AT was correctely identified


ABLATIONABLATION

• ILATILAT as dual-loop

• CONDUCTION CONDUCTION BLOCK BLOCK across the isthmus was able to interrupt the AT

• ECHOCARDIOGRAPHYECHOCARDIOGRAPHY after ablation


POST-ABLATION POST-ABLATION MANAGEMENTMANAGEMENT

• SYSTEMIC ANTICOAGULATIONSYSTEMIC ANTICOAGULATION was starting with heparin-Na+ six hours after the end of the procedure

• ORAL ANTICOAGULATIONORAL ANTICOAGULATION 24 hs later


• After 6 month FU, FREE FREE from AT without AADs.• Our FU consists in PERIODIC PERIODIC clinical CTR, baseline ECG and Holter monitoring (each month) • IMPROVEMENTIMPROVEMENT of Clinical parameters (QOL, effort’s tollerance, NYHA) and Echo parameters (LVEF 50%).

POST-ABLATION POST-ABLATION MANAGEMENTMANAGEMENT


• CONVENTIONAL CONVENTIONAL MAPPING MAPPING is not really appropriate for ILAT ILAT mapping, because very limited understanding of these complex arrhythmias (highly variable from one patient to the other).

• The MAIN MAIN DRAWBACKDRAWBACK of EP criteria is that the reconstruction of complete circuit(s) is EXTREMELY EXTREMELY DIFFICULT DIFFICULT to achieve.

CONCLUSION (1)CONCLUSION (1)


• NAVX TECHNOLOGYNAVX TECHNOLOGY allows a REALISTIC 3DREALISTIC 3D

• The catheter tracking and 3-D construction is feasible using CUTANEOUS PATCHES CUTANEOUS PATCHES and CONVENTIONAL CONVENTIONAL Catheters • This approach may be

USEFULUSEFUL in the treatment of pts with cardiac arrhythmias where ablation therapy is primarily

ANATOMICALLY BASEDANATOMICALLY BASED

CONCLUSION (2)CONCLUSION (2)

2006 bologna, caso clinico. ablazione transcatetere di tachicardia atriale incisionale

Health & Medicine

Transcript of 2006 bologna, caso clinico. ablazione transcatetere di tachicardia atriale incisionale