Christopher Woods, MD PhD

Peninsula-Sequoia Cardiac Electrophysiology

Palo Alto Medical Foundation

Ventricular Arrhythmias: Ablating Our Way Out of Cardiomyopathy

and Sudden Cardiac Death, Is this the Final Frontier?

R43 NIH grant for work investigating a novel arrhythmia mapping system

Disclosures

Ventricular Tachycardia

Manifestations of Ventricular Tachycardia (VT)

Premature Ventricular Contractions (PVCs) Non-sustained ventricular tachycardia (NSVT) 3 or more consecutive QRS

complexes of ventricular origin at rate of more than 100 bpm Sustained VT Lasts more than 30 seconds, usually requires intervention for

termination Monomorphic VT Uniform QRS configuration Polymorphic VT Beat to beat variation in QRS configuration Electrical storm > 3 VT/VF episodes in 24 hours

Clinical Consequences of VT, PVCs

Sudden cardiac arrest Cardiomyopathy Syncope, near syncope Palpitations

Deo R, Albert C. Circulation 2012;125:620-637

Monomorphic vs Polymorphic vs Fibrillation

Monomoprhic VT: Idiopathic Scar

Polymorphic VT: Ischemia Long QT syndrome Brugada syndrome Short coupled Torsades Short QT syndrome Catecholamine polymorphic VT Early Repolarization/Idiopathic VF

Ventricular Fibrillation

Monomorphic VT

Idiopathic VTFocal VT associated with structural heart diseaseRe-entry in Scar

Ischemic Cardiomyopathy Non-ischemic Cardiomyopathy

Idiopathic dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy (ARVC) Infiltrative cardiomyopathy- amyloidosis, sarcoidosis Chagas disease

Idiopathic VT or PVCs

Focal process without structural disease Localized by ECG 2/3 RVOT, most others LVOT

Mitral Annular PVCs Fasicular VT Papillary Muscle VT Epicardial VT with coronary venous system

Reason to treat: Symptoms PVC induced cardiomyopathy Catheter ablation can be curative

Circ Arrhythm Electrophysiol. 2012;5:229-236.

PVC Induced Cardiomyopathy

Niwano S, Heart. 2009;95: 12301237. ~20,000 per day

ECG/Holter

Echo

Stress Testing/cMRI

Radiofrequency Catheter Ablation

Ablation can be curative PVC 71927; 54% burden EF 33%

PVC 42; 0.05% EF 53%

2 seconds of ablation

23 year-old with near syncope

Focal VT from Aortic Valve Suture Ring Scar

In 20% of patients with structurally abnormal hearts referred to us for VT, the VT was focal AND NOT ASSOCIATED WITH SCAR

Ventricular Tachycardia Associated with Structural Heart Disease: Scar Based

ICD is mandatory in this population

Class I Recommendations for ICD Defibrillators Level of Evidence A ICM LVEF 35% >40 days post-MI, NYHA II or III ICM LVEF 30%, >40 days post-MI, NYHA I Survivors of Sudden Cardiac Arrest

Level of Evidence B NIDCM LVEF 35%, NYHA II or III ICM LVEF 35-40%, NSVT and inducible ventricular fibrillation or sustained ventricular tachycardia at electrophysiological study With structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable With syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study

Primary Prevention Trials

Sudden Cardiac Death in Heart Failure; NEJM 2005 Multicenter Automatic Defibrillator Implantation Trial; NEJM 2002

Two options for ICD

Transvenous ICD Subcutaneous ICD

TV leads1: 95-99% successful conversion 9.1% complication rate over 16 months

Lead displacement 3.1% Pneumothorax 1.1% hematoma 1.2%. Infection rate 1.5%. Lead failure 5-40% depending on trial

SubQ ICD 100 % successful conversion Complication-free rates were 97 and 94%, at 30 and 360 days NO electrode failures No S-ICDrelated endocarditis or bacteremia

1 Ezzat VA, etal OpenHeart 2015;

Circulation. 2008; 117: 2721-2723

JOURNAL OF T H E AMERICAN COL LE GE OF CARD IOLOGY VOL. 65, NO. 16, 2015

14,703 post-MI patients depressed EF

RCT looking at Rx of Valsartan

83% of SCA occurred after hospital discharge.

74% of those resuscitated in the first 30 days were alive at 1 year

1 Solomon SD, et al. Sudden Death in Patients with Myocardial Infarction and Left Ventricular Dysfunction, Heart Failure, or Both. NEJM 2005; 352: 2581-2588.

Valsartan in Acute Myocardial Infarction Trial Investigators (VALIANT trial)

It turns out, ICD Does Not Improve Survival Immediately after MI (first 40 days)

1. EF 40% on day 531 2. Non-sustained ventricular tachycardia

J Am Coll Cardiol. 2006;47(12):2477-2482 NEngl J Med 2009;361:1427-36

The Defibrillator in Acute Myocardial Infarction Trial (DINAMIT)

Immediate Risk Stratification Improves Survival (IRIS) trial

1. EF 35% on day 535 2. Depressed heart rate variability

LifeVest

No society guidelines No RCT yet 150 joule biphasic shock Patient may inhibit shock while

conscious Captures ECG 30 seconds before

event Stores up to 75 minutes of ECG

J Am Coll Cardiol. 2010;56(3):194-203.

Heart Rhythm, Vol 12, No 9, September 2015

2061 patients from 12 international Centers Predictors of VT recurrence: NICM NYHA status Epicardial ablation More induced VTs ICD Lower EF Electrical >2 antiarrhythmic drug

70% freedom @ 1 year

VT in Ischemic Cardiomyopathy in a patient with large inferior Anterior MI

VT in Idiopathic NICM

95% of VT is unstable

Epicardia VT

Epicardial Approach

Summary Ventricular tachycardia is an important cause of sudden cardiac arrest ECG characteristics can localize the site and origin of VT Idiopathic VT

Monomorphic VT / Frequent PVCs curable with catheter ablation Polymorphic VT treated with ICD and drugs

In structural heart disease, ICD therapy is indicated in patients with ICM LVEF 35% >40 days post-MI, NYHA II or III ICM LVEF 30%, >40 days post-MI, NYHA I

Management of VT associated with structural heart disease beta-blockers, antiarrhythmic drugs, ICD Catheter ablation is a very important palliative measure with ~60-70% one

year freedom from recurrent VT

Slide Number 1Slide Number 2Ventricular TachycardiaManifestations of Ventricular Tachycardia (VT)Clinical Consequences of VT, PVCsMonomorphic vs Polymorphic vs FibrillationMonomorphic VTIdiopathic VT or PVCsPVC Induced CardiomyopathySlide Number 10Radiofrequency Catheter AblationAblation can be curative23 year-old with near syncopeFocal VT from Aortic Valve Suture Ring ScarSlide Number 15Ventricular Tachycardia Associated with Structural Heart Disease:Scar BasedSlide Number 17Primary Prevention TrialsTwo options for ICDSlide Number 20Slide Number 21Slide Number 22LifeVestSlide Number 24Slide Number 25Slide Number 26VT in Ischemic Cardiomyopathy in a patient with large inferior Anterior MISlide Number 28Slide Number 29Slide Number 30Summary