epicardial technology and multidisciplinary approach for...

Epicardial Technology and multidisciplinary approach for

Ventricular Arrhythmias:present and future

Paolo Della BellaOttavio Alfieri

Elisabetta La PennaArrhythmia Unit and EP Laboratories- Cardiac Surgery

San Raffaele Hospital Milan, Italy

• Surgical access– Unfeasible access to the LV

– Epicardial adhesions

– Previous cardiac surgery

• Epicardial mapping/ablation– Need for extensive epicardial ablation (Cryoprobe)

– Need to displace the course of coronary artery/phrenicnerve

– Indication to concomitant cardiac surgery

Surgical VT ablation- Rationale

Surgical VT ablation- Indications from current Guidelines

1204 Ablation procedures in 958 patients(2010-2017)

VT etiologies

45%

26%

9%

8%5%

1% 6%Underlying heart disease

CAD IDCM ARVD Myocarditis Valvular Congenital Other non ischemic

Ventricular Tachycardia ablation in the setting of SHD- OSR experience

Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017

Surgical access-ablation in 43/958 patients (4,4%)

IHD40%

IDCM26%

Myocarditis14%

Valvular16%

Congenital2%

HCM2%

VT etiologies

Clinical Characteristics Pts, N (%)

Age, ys, Mean±SD 63±11

EF, %, Mean±SD 34±13

Male 42 (97,6%)

NYHA Class I-II 28 (65,1%)

NYHA Class III-IV 15 (34,9%)

Paroxysmal VT 27 (62,8%)

Incessant VT 2(4,6%)

Electrical Storm 14(32,6%)

ICD 41 (95,3%)

Failed AADs 40 (93.1%)

Failed Ablation 26 (60,4%)

Previous Surgery 16 (37,6%)

Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017

43 patients

Surgical access

Indications to surgical approach/ablation:

Previous cardiac surgery: 13/43 pts (30,2%)Double prosthetic valve: 3/43 pts (7%)Failed percutaneous epi access: 8/43 pts (18,6%)Apical thrombus: 8/43 pts (18,6%)Deep substrates: 6/43 pts (14%)Indication to aneurismectomy: 2/43 pts (4,6%)Indication to cardiac surgery: 1 pt (2,4%)Previous epi ablation limited by CA/PN: 2/43 pts (4,6%)

In-procedure switch to epicardial surgical approach in 3 pts (failed endo ablation)

Thoracotomy Sternotomy Transapical Marfan

18

10

3

12

Male, 41 yo

2 previous failed epicardial ablation attempts (other Country)

Recurrent VTs treated by ATP/shocks

Previous single chamber ICD implant

Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017

Clinical case

Chest CT scan: posterior slice Chest CT scan: anterior slice

Multidisciplinary approach for VAs: the OSR experienceClinical Case

Procedure Data-1

Multidisciplinary approach for VAs: the OSR experienceClinical case

Procedure data

Multidisciplinary approach for VAs: the OSR experienceClinical Case

Procedure data-Epicardial Mapping

Multidisciplinary approach for VAs: the OSR experienceClinical Case

Procedure data- Endocardial mapping

Multidisciplinary approach for VAs: the OSR experienceClinical case

Procedure Data-Ablation Endpoint

Remap

Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017

51%

19%

30%

Endo Endo-epi Epi

77%

14%

7%

2%

No support ECMO IABP VAD

Ablation approach Haemodynamic support

16%

84%

Cryo RF

Ablation source

12%

70%

16%

2%

EPS not done Class A Class B Class C

FU 45+24 months:

VT recurrence: 14 (32%)AHF: 12 (27,9%)

Redo percutaneous procedure: 2 pts (4,6%)

Acute procedure success

Multidisciplinary approach for VAs: the OSR experienceJan 2010-Oct 2017

In Hospital Outcome

VT recurrence 5/43 (11,6%)

ES recurrence 2/43 (4,6%)

Complications:

Pericardial effusion 1 (2,3%)

Pleural effusion 1 (2,3%)

Infection of the surgical access 2 (4,6%)

Death (cardiogenic shock) 1 (2,3%)

• Although the indication to surgical access/ablation for treatment of VAs is limited, the cooperation betweenelectrophisiologists and surgeons is the key to success in verydifferent complex settings.

• Long-term success and acute complication rates are quiteacceptable in this high-risk population.

Conclusions