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Ablation Strategy for Ventricular Arrhythmia
Storm in Ischemic Cardiomyopathy
Haris M. HaqqaniMBBS(Hons) PhD FRACP FCSANZ FHRS FACC
Associate Professor of Medicine, The University of Queensland
Senior Consultant Electrophysiologist, The Prince Charles Hospital
Brisbane, Australia
Disclosures
Company Name Relationship
Biosense Webster Research grant
Speaking honoraria
Boston Scientific Scientific advisory board
Speaking honoraria
Medtronic Scientific advisory board
Speaking honoraria
Abbott Speaking honoraria
The presenter has received financial support from the
organizations identified below for the relationships listed:
KHRS Scientific Sessions 2018, Seoul8 June 2018 2
8 June 2018 KHRS Scientific Sessions 2018, Seoul 3
Ablation strategies for
electrical storm in ICM
Ablation of inducible VTs
(+/- MCS)
Substrate ablation in
SR (+/- MCS)
Renal denervation by
catheter ablation
Ablation of scar border zone PVC
triggers of VT
Ablation of PVC triggers
of PVT/VF
Neuraxial
autonomic
modulation
Issue #1: Heterogeneity in the
definition of electrical storm
8 June 2018 KHRS Scientific Sessions 2018, Seoul 4
Commonest definition:
Three or more separate episodes of VA
requiring intervention (usually ICD
therapy) within a 24 hour period
Sagone. J Atr Fib. 2015
Issue #2: Variability in the
clinical presentation within
this definition
8 June 2018 KHRS Scientific Sessions 2018, Seoul 5
Patient 1:
64yo male with ICM, LVEF 32%
Develops sudden dyspnea
Sustains two ICD shocks at home
Two further shocks in ambulance on
12 episodes of ATP terminated
SMVT in 3 days
4 accelerated to PMVT CV
No further VA on amio/lignocaine
Issue #2: Variability in the
clinical presentation within
this definition
8 June 2018 KHRS Scientific Sessions 2018, Seoul 6
Patient 2:
51yo man with ICM, LVEF 38%
Collapses at auction
13 ICD shocks over 20 mins
Initial 3 due to rapid SMVT
Subsequent shocks due to PVT
Ongoing episodes in CCU
despite amio/lignocaine
Issue #3: Variability in the
ventricular arrhythmia
responsible for the storm
8 June 2018 KHRS Scientific Sessions 2018, Seoul 7Sagone. J Atr Fib. 2015
8 June 2018 KHRS Scientific Sessions 2018, Seoul 8Nayyer et. al. EHJ. 2013
Issue #3: Variability in the
ventricular arrhythmia
responsible for the storm
Mechanism:
• Scar-related re-entry most common
mechanism 83% pts
• Purkinje-related or myocardial PVC
present in 14%
• Macroreentry within the His-Purkinje
system responsible for 3%
Case
• 41 year old man, smoker
• Type A personality ++, accountant
• presented late with inferior MI
• cath:
8 June 2018 KHRS Scientific Sessions 2018, Seoul 9
8 June 2018 KHRS Scientific Sessions 2018, Seoul 10
8 June 2018 KHRS Scientific Sessions 2018, Seoul 11
8 June 2018 KHRS Scientific Sessions 2018, Seoul 12
Case
• LVEF 33% at that stage, inferolateral hypokinesis
• CABG x3: LIMALAD, SVGPDA, SVGM1
• uncomplicated recovery apart from significant
bibasal atelectasis
• about to be discharged late on day 8…
8 June 2018 KHRS Scientific Sessions 2018, Seoul 13
8 June 2018 KHRS Scientific Sessions 2018, Seoul 14
8 June 2018 KHRS Scientific Sessions 2018, Seoul 15
• > 50 sustained episodes, most terminated by coughing; incessant non-sustained episodes
• 14 external shocks required initially
• ongoing episodes in ICU despite esmolol, lidocaine, amiodarone, midazolam and intubation with general anesthesia
• ECMO pump being primed ….
Case
8 June 2018 KHRS Scientific Sessions 2018, Seoul 16
I
II
III
aVR
aVL
aVF
V1
V6
8 June 2018 KHRS Scientific Sessions 2018, Seoul 17
I
II
III
aVR
aVL
aVF
V1
V6
EP lab at
midnight
8 June 2018 KHRS Scientific Sessions 2018, Seoul 18
I
II
III
aVR
aVL
aVF
V1
V6
Multiple
DCCV
required
8 June 2018 KHRS Scientific Sessions 2018, Seoul 19
On postero-
medial papillary
muscle
8 June 2018 KHRS Scientific Sessions 2018, Seoul 20
I
II
III
aVR
aVL
aVF
V1
V6
Pacemap
from PPM
8 June 2018 KHRS Scientific Sessions 2018, Seoul 21
I
II
III
aVR
aVL
aVF
V1
V6
MAPd
MAPp
Fragmented
Purkinje-like
potentials
on PPM
8 June 2018 KHRS Scientific Sessions 2018, Seoul 22
I
II
III
aVR
aVL
aVF
V1
V6
MAPd
MAPp
Earlier at
more SR
fractionated
sites on
PPM
8 June 2018 KHRS Scientific Sessions 2018, Seoul 23
I
II
III
aVR
aVL
aVF
V1
V6
MAPd
MAPp
Very early
fractionated
potentials
on PPM
8 June 2018 KHRS Scientific Sessions 2018, Seoul 24
I
II
III
aVR
aVL
aVF
V1
V6
MAPd
MAPp
8 June 2018 KHRS Scientific Sessions 2018, Seoul 25
8 June 2018 KHRS Scientific Sessions 2018, Seoul 26
8 June 2018 KHRS Scientific Sessions 2018, Seoul 27
I
II
III
aVR
aVL
aVF
V1
V6
MAPd
MAPp
No inducible
VT / VF with
aggressive
PVS at case
end
8 June 2018 KHRS Scientific Sessions 2018, Seoul 28
Follow-up
• ICD inserted pre-discharge
• No ICD events over 6 years
• No significant ectopy on PVC counters
• LVEF 50% on medical therapy
• No significant mitral regurgitation on
follow-up echocardiograms
8 June 2018 KHRS Scientific Sessions 2018, Seoul 29
Surviving myocytes/Purkinje
within non-uniform scar
Inhomogeneous
slowed conduction
Conducting
channels in scar
Reentrant VT
Substrate for
scar-related VT
Waller et. al. AJC 1998
De Bakker JMT. Heart Rhythm 2005
Stevenson W. HRS 20058 June 2018 KHRS Scientific Sessions 2018, Seoul 30
Channel / Isthmus
ExitOuter Loop
Entrance
Bystander
RF
RF
Courtesy of
Dr W Stevenson
8 June 2018 KHRS Scientific Sessions 2018, Seoul 31
>1.5 mV
<0.5 mV
I
II
III
aVR
aVL
aVF
V1
V6
68yo man
ICM, EF 20%
ICD shocks
apex
base
RAO8 June 2018 KHRS Scientific Sessions 2018, Seoul 32
Entrainment mapping
I
II
III
aVR
aVL
aVF
V1
V6
MAPd
MAPp
8 June 2018 KHRS Scientific Sessions 2018, Seoul 33
Early termination with RF ablation
I
II
III
aVR
aVL
aVF
V1
V6
MAPd
MAPp
8 June 2018 KHRS Scientific Sessions 2018, Seoul 34
8 June 2018 KHRS Scientific Sessions 2018, Seoul 35Ahn J, … Kim YH. et. al. KCJ. 2018
8 June 2018 KHRS Scientific Sessions 2018, Seoul 36Baratto et. al. Circ AE 2016
8 June 2018 KHRS Scientific Sessions 2018, Seoul 37Baratto et. al. Circ AE 2016
8 June 2018 KHRS Scientific Sessions 2018, Seoul 38Baratto et. al. Circ AE 2016
8 June 2018 KHRS Scientific Sessions 2018, Seoul 39Turagam et. al. JACC EP 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 40Muser et. al. WJC. 2017
Marchlinski FE et. al. Circ 2000
Substrate
mapping &
ablation
>1.5 mV
<0.5 mV
8 June 2018 KHRS Scientific Sessions 2018, Seoul 41
8 June 2018 KHRS Scientific Sessions 2018, Seoul 42
Substrate ablation
strategies in ICM
Electrogram guided; ILP,
LAVA
Pacemapguided, long
S-QRS
Scar dechanneling
Core isolation
Scar homogenization
>1.5 mV
<0.5 mV
8 June 2018 KHRS Scientific Sessions 2018, Seoul 43
>1.5 mV
<0.5 mV
8 June 2018 KHRS Scientific Sessions 2018, Seoul 44
Final lesion set
8 June 2018 KHRS Scientific Sessions 2018, Seoul 45
Outcomes
Nayyer et. al. EHJ. 2013
• High procedural success rates:
72% no inducible VT
91% no inducible clinical VT
• Multiple procedures required in 19% (1.3 / pt)
• Low complication rate:
procedural mortality 0.6%
2% MI, tamponade, stroke, CHB
• VA recurrence rate 28% over 61 week f/u
higher recurrence with SMVT vs. PVT
94% freedom from VA storm
• 78 deaths (17%): 62% form
8 June 2018 KHRS Scientific Sessions 2018, Seoul 46Muser et. al. WJC. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 47Kumar et. al. JCE. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 48Kumar et. al. JCE. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 49Muser et. al. JACC EP. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 50Muser et. al. JACC EP. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 51Muser et. al. JACC EP. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 52Muser et. al. JACC EP. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 53Muser et. al. JACC EP. 2017
8 June 2018 KHRS Scientific Sessions 2018, Seoul 54Vergara et. al. HRJ. 2018
8 June 2018 KHRS Scientific Sessions 2018, Seoul 55Vergara et. al. HRJ. 2018
Conclusions
• Electrical storm in ischemic cardiomyopathy is a
heterogenous but concerning condition
• The ablation strategy chosen depends significantly on
the mode of presentation, degree of hemodynamic
effect and type of ventricular arrhythmia
• Mechanical circulatory support may be required
• Catheter ablation patients have low observed rates of
recurrent electrical storm
• Catheter ablation is associated with increased survival
8 June 2018 KHRS Scientific Sessions 2018, Seoul 56
8 June 2018 KHRS Scientific Sessions 2018, Seoul 57