The Role of Catheter Ablation in the Management of Ventricular Tachycardia
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1 The Role of Catheter Ablation in the Management of Ventricular Tachycardia Hugh Calkins M.D. Professor of Medicine Director of Electrophysiology The Johns Hopkins Medical Institutions Cardiology Update 2015 Davos Switzerland
2 Disclosures Consultant and /or Honoraria: Daiichi Sankyo Boehringer - ingelheim Atricure Medtronic St Jude Medical
3 Goals Historical Perspective on VT Ablation Technique and Role of Catheter ablation for Treatment of Idiopathic VT Technique and Role of Catheter Ablation for Treatment of VT in Patients with Structural Heart Disease Current Status of Multicenter Clinical Trials of VT Ablation Conclusion and Final Thoughts
4 Goals Historical Perspective on VT Ablation Technique and Role of Catheter ablation for Treatment of Idiopathic VT Technique and Role of Catheter Ablation for Treatment of VT in Patients with Structural Heart Disease Current Status of Multicenter Clinical Trials of VT Ablation Conclusion and Final Thoughts
5 Surgical Treatment of Ventricular Tachycardia first reported in the mid 1970 s Guiraudon; encircling endocardial ventriculotomy Josephson, Harken; endocardial excision
6 Surgical Treatment of Ventricular Tachycardia
7
8 Catheter Ablation Using DC Shock Energy Gallagher et al, N Engl J Med 306: 194, 1982
9 Electrode Catheter Ablation of Refractory Focal Ventricular Tachycardia Geoffrey O. Hartzler, MD, FACC JACC 1983; 2: patients underwent DC shock ablation 1 idiopathic RVOT VT 2 recurrent VT after failed aneurysmectomy
10 The Era of RF Ablation: present
11 Goals Historical Perspective on VT Ablation Technique and Role of Catheter ablation for Treatment of Idiopathic VT Technique and Role of Catheter Ablation for Treatment of VT in Patients with Structural Heart Disease Current Status of Multicenter Clinical Trials of VT Ablation Conclusion and Final Thoughts
12 Idiopathic Ventricular Tachycardia
13 New Mapping Tools
14 Outcomes of Catheter Ablation of Idiopathic Ventricular Tachycardia Acute Efficacy > 90 % Long Term Efficacy / Cure > 85% Major Complications < 1% Clinical Role First line
15
16 Goals Historical Perspective on VT Ablation Technique and Role of Catheter ablation for Treatment of Idiopathic VT Technique and Role of Catheter Ablation for Treatment of VT in Patients with Structural Heart Disease Current Status of Multicenter Clinical Trials of VT Ablation Conclusion and Final Thoughts
17 Catheter Ablation Ventricular Tachycardia in Patients with Structural Heart Disease Stevenson Circ 1992
18
19
20 Outcomes of Catheter Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease Acute Success % Longer Term Efficacy (with AA drugs) 50% Major Complications 5-15% Clinical Role Second line
21 146 pts, SHD (IHD 82%), yrs, EF % Irrigated RF ablation 3 VTs per patient Acute success in 75% mappable, 41% all VTs Major compl: 8% (death in 2.7%) Amiodarone at discharge in 42% 46% recurrence rate during d fu 25% mortality at one year follow-up JACC 2000
22 Circ pts, IHD, 68 yrs, EF 25 % Irrigated RF ablation 3 VTs per patient Acute success in 49% Major compl: Major complications 10.3 Death within 7 days -7 pts (3%) AA drugs at last fu in 72% 47% recurrence rate at 6 m fu 18% 1 year mortality Circ 2008
23 63 pts, IHD, yrs, EF % Irrigated RF ablation 3 VTs per patient Acute success in 81% Major compl: 1.5% Amiodarone in 65% 49% recurrence rate during m fu JCVEP 2010
24
25 Ongoing Multicenter Trials of VT Ablation - Current Status - Mantra VT: IHD VT randomized to abl or AA drugs Star VT - clin or induc VT undergoing ICD implant, IHD and NIHD, Abl vs dugs Aspire VT IHD VT randomized to early VT abl & drugs verus drugs closed due to poor enrollment Vanish - VT abl in IHD pts with VT despite AA drugs randomized to more AA drugs or CA and drugs enrollment complete
26 Ongoing Multicenter Trials of VT Ablation - Current Status - Mantra VT: IHD VT randomized to abl or AA drugs Star VT - clin or induc VT undergoing ICD implant, IHD and NIHD, Abl vs dugs Aspire VT IHD VT randomized to early VT abl & drugs verus drugs closed due to poor enrollment Vanish - VT abl in IHD pts with VT despite AA drugs randomized to more AA drugs or CA and drugs enrollment complete
27 Logistical Challenges that Impair VT Ablation Patients present at inconvenient times Procedure rooms are full due to the success of AF ablation! The numbers of patients are relatively small The days of VT arising from large aneurysms are over The substrates and extent of disease differ markedly Multiple mechanisms for VT often exist (i.e. ischemia) VT ablation is technically challenging The lesions we can create with RF energy may not be large enough. Cases are long Risks are high Not a money maker Amiodarone is widely available
28 Summary and Conclusion Catheter ablation of idiopathic VT is a safe, effective, and curative procedure. Catheter ablation of VT in the setting of structural heart disease is challenging. This is a complex procedure associated with moderate efficacy despite continued AA AA drug therapy in most patients, and a significant incidence of complications including mortality. Despite these challenges, this procedure plays an Important role in patient management and represents the true frontier of catheter ablation in 2015.
29 Thank You
Presenter Disclosure Information
2:15 3 pm Managing Arrhythmias in Primary Care Presenter Disclosure Information The following relationships exist related to this presentation: Raul Mitrani, MD, FACC, FHRS: Speakers Bureau for Medtronic.
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