The 7 th international Scientific Congress of The Egyptian Cardiac Rhythm Association ECRA Highlights of the Conference VT

Transcription

1 The 7 th international Scientific Congress of The Egyptian Cardiac Rhythm Association ECRA Highlights of the Conference VT

2 Highlights of VT Two sessions for VT 9 lectures 1 state of art 3 debates Three case presentations

3 Conference Highlights Lectures I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Said Khaled 2 New insight i of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imaging in Substrate mapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

4 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imaging in Substrate mapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

5 ECG diagnosis & localization of VT Said Khaled

6 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imaging in Substrate mapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

7 New insight of drug therapy in VT Prof. Samir Morcos Rafla Alexandria Univ.

8 Summary of the molecular targets and potential therapeutic uses of a selection of drugs that block K + channels and that have been developed to treat arrhythmia. Drug Company Molecular target Therapeutic use Amiodarone Dronedarone Sanofi Wyeth-Ayerst Sanofi-Aventis Multiple: Na +, Ca 2+ and K + channel blockade Multiple: similar to amiodarone Dofetilide Pfizer I Kr -blocker D/L-sotalol/D-sotalol Vernakalant Berlex/Bristol Myers Squibb I Kr K + channel blockade (and β-bl) Maintenance of sinus rhythm Maintenance of sinus rhythm Maintenance of sinus rhythm Maintenance of sinus rhythm N i faf Cardiome Pharma Corp Mixed Na+, K + channel Cardioversion of, blocker maintenance of SR Azilimide Proctor and Gamble I Kr and I Ks blockade NIP-151 Nissan Pharmaceuticals I Kach -blocker 8 Maintenance of sinus rhythm Maintenance of sinus rhythm

9 Ranolazine New data presented this week has shown that the novel antianginal agent ranolazine (Ranexa), an inhibitor of the late phase of the sodium current, is safe, with investigators finding no evidence of an excess risk of arrhythmia or sudden cardiac death, according to an analysis of the MERLIN TIMI 36 study. Ranolazine actually resulted in significant decreases in many types of arrhythmias--in particular, ventricular tachycardia. 9

10 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imaging in Substrate mapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

11 Hesham Al-Aassar, MD Professor of Critical Care Medicine Department Cairo University

12 Results P1 P2 P1 P2 Idiopathic VT P2 P2 No of patients I. Outflow tract VT A. RVOT. 12 pts B. LVOT: 1. Aortic cusps. 3 pts 2. LV basal. 3 pts II. Fascicular VT: A. LPF VT. 4 pts B. LAF VT. 2 pts C. Left upper septal fascicular VT. 1pts

13 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imaging in Substrate mapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

14 Ischemic VT Ablation Where Do We Stand? Walid Saliba, M.D. Director, EP Lab Section of Cardiac Electrophysiology & Pacing Department of Cardiovascular Medicine The Cleveland Clinic Cleveland, l Ohio USA

15 Ischemic VT: Activation Map 1 55 year old, AMI Recurrent VT

16 Step 1 Create Voltage Map to characterize the anatomic substrate Step 2 Analyze 12 lead ECG during all induced and spontaneous VT Step 3 Pace along border zone to identify best 12 lead ECG match(es) BIPOLAR VOLTAGE MAP ANTERIOR MI Normal > 1.5mV BORDER ZONE DENSE SCAR BORDER ZONE DENSE SCAR B o r d e r Z o n e TBAB Dense Scar SHALLOW RAO LAO <0.5mV X = site of good pacemaps in patient with 3 VT morphologies

17 5 Patients days post Ant MI with recurrent PMVT: All PVC s arise from the Purkinje arborization in the scar border zone. PVC s were right bundle-branch block in all five patients Ablation at these sites eliminated all PVC s Follow-up at t16± 5 months showed no recurrence of arrhythmia J Am Coll Cardiol 2004;44:1700 6

18 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imaging in Substrate mapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

19 Needle angle is adjusted according to the region that the operator wishes to access. This region is most frequently the medial third of the right ventricle, where, based on the coronary angiography, no major coronary vessels arefound. PERICARDIAL PUNCTURE: HOW TO PERFORM IT Transthoracic Epicardial Catheter Ablation to Treat Recurrent Ventricular Tachycardia E. Sosa, M. Scanavacca, and A d Avila Current Cardiology Reports 2001, 3: HSR - MILANO

20 INDICATION TO EPICARDIAL ABLATION 2 ECG CRITERIA Sensitivity Specificity Pseudo-delta wave >34 ms Intrinsecoid deflection time >/= 85 ms 83% 95% 87% 90% RS complex duration >/= 121 ms 76% 85% Group A: Epi Group B: Endo HSR - MILANO

21 INDICATION TO EPICARDIAL ABLATION 3 - IMAGING TO GUIDE THE IDENTIFICATION OF EPICARDIAL VT SUBSTRATE: PRIMARY APPROACH HSR - MILANO

22 CURRENT LIMITATIONS FOR FURTHER DEVELOPMENT Deflectable sheaths Dedicated RF delivering system (selective and firmer contact with epicardial layers, avoidance of collateral damage) Research for energy sources able to overcome the isolating properties of the fat tissue HSR - MILANO

23 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imaging in Substrate mapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

24 Endocardial di vs. Epicardial lablation of VT Walid Saliba, MD Director, EP Lab Cardiac Electrophysiology Heart and Vascular Institute

25 Complications Entrapment in the diaphragm Subdiapragmatic vascular bleeding Tamponnade RV or LV perforation Damage to coronary artery : acute chronic Phrenic nerve damage Post pericardiotomy syndrome: Constrictive pericarditis

26 Epicardial Access with Adhesions: Localized Effusion

27 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imagingin in Substratemapping Tamer Fahmy 8 Ablationof incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

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30 PET/CT integration

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33 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imagingin in Substratemapping Tamer Fahmy 8 Ablation of incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

34 Catheter ablation of incessant ventricular tachycardia Hans Kottkamp, M.D. Clinic Hirslanden Heart Center Zurich, Switzerland

35 Catheter ablation on incessant ventricular tachycardia Substrate mapping for VT ablation Voltage map Inferior view 4.11 mv MA Septum mv mv mv 1 cm Free wall L-3744 Apex

36 Inferior view 4.11 mv Septum MA 006mV mv mv Apex Free wall 1 cm L-3744 I II V1 V6 Abl. RVA Late potentials in the scar zone LP Abl. RVA I II V1 V6 Late potentials in the border zone V Abl. LP RVA I II V1 V6 Abl. RVA No potentials in dense scar no potential at all Abl. Abl. RVA RVA

37 Inferior view MA Septum 4.11 mv I II Diastolic potential (Elg-QRS 75 ms) 006mV 0.06 V1 V6 1 cm Free wall L-3744 Abl. RVA I II III avr avl avf V1 V2 V3 V4 V5 V6 Concealed entrainment I II III avr avl avf V1 V2 V3 V4 V5 V6 RF application VT termination during ablation

38 Conference Highlights I. Lectures VT Lecture Presenter 1 ECG Criteria of VT Diagnosis and Localization Said Khaled 2 New insight of Drug therapy Samir Rafla 3 Idiopathic VT ablation Hesham El Aasar 4 IschemicVT ablation Walid Saliba 5 Epicardial approach Giuseppe Maccabelli 6 Enodocardial vs Epicardial ablation of VT Walid Saliba 7 Role of imagingin in Substratemapping Tamer Fahmy 8 Ablation of incessent VT Hans Kottkamp 9 Ablation of Idiopathic VF Hans Kottkamp 10 State of art PVC related cardiomyopath Hans Kottkamp

39 Catheter ablation of idiopathic ventricular fibrillation Hans Kottkamp, M.D. Clinic Hirslanden Heart Center Zurich, Switzerland 10

40 Catheter ablation of idiopathic ventricular fibrillation Idiopathic ventricular fibrillation Mapping of the initiating trigger Haissaguerre M, et al.: Lancet 2002;359:

41 Catheter ablation of idiopathic ventricular fibrillation Malignant entity in RVOT arrhythmias Noda T, et al.: JACC 2005;46:

42 Catheter ablation of idiopathic ventricular fibrillation Mapping and ablation of VF triggers in LQTS and Brugada Haissaguerre M, et al.: Circulation 2003;108:

43 Catheter ablation of idiopathic ventricular fibrillation Mapping and ablation of VF triggers in LQTS and Brugada Haissaguerre M, et al.: Circulation 2003;108:

44 Debates Debate Pro Con 1 Catheter ablation in VT in HansKottlkamp WalidSaliba structural Ht disease will replace ICD 2 Ischemic VT in ICD pts Hans Kottkamp Walid Saliba Ablate or wait for the stor 3 PVCablation True or Myth Walid Saliba Gamal Shaaban

45 Debates Debate Pro Con 1 Catheter ablation in VT in HansKottlkamp WalidSaliba structural Ht disease will replace ICD 2 Ischemic VT in ICD pts Hans Kottkamp Walid Saliba Ablate or wait for the stor 3 PVCablation True or Myth Walid Saliba Gamal Shaaban