ADVANCES IN CATHETER ABLATION OF VT

Kalyanam Shivkumar, MD PhD UCLA Cardiac Arrhythmia Center & EP Programs

UCLA Interventional CV ProgramsUCLA Health System

David Geffen School of Medicine at UCLA

Cardiac Arrhythmia Center

Acknowledgements• American Heart Association• NIH• NIH-(Bio Engineering Research Partnership)

• DISCLOSURES:University of California (UCLA campus) Patents: catheter technology,

embolism prevention technology, minimally invasive methods for cardiac interventions

• 52 year old female with monomorphic PVC’s and cardiomyopathy but no evidence of scar on ceMRI

• 22 year old college student resuscitated from sudden death with monomorphic PVC’s

• 62 year old male post MI EF of 30% with syncope & VT storm

• 32 year old male with ‘ARVC’ (previous failed ablation) presents with incessant VT (multiple morphologies)-received 160 shocks (ICD-battery exhausted-skin burns)-intubated sedated-unstable death is imminent

52 yr old female with MMVT that is drug refractory with low EF

UCLA Cardiac Arrhythmia Center: Outflow VT Ablation Playbook: 14 sampling sites

RAO LAO

UCLA CARDIAC ARRHYTHMIA CENTER

RVOT 1: post

RVOT 2: Ant

RVOT 3: Lat

RVOT 4: septal

RVOT 5: above pulmonic V

RCC: ms

RVRVHis

HisCS

CS

GCV/AIV: msMPA

MPA

Ao Ao

AIV d: ms

LCC: ms

AIV p: ms

AIV d: ms

AIV p: ms

RVOT 5 above PV: ms

AMC: ms

RVOT 1: ms

RVOT 3: msRVOT 4: ms

RVOT 2: ms

RVOT 5 above PV: ms

LMCA: ms

GCV: ms

LV: ms

Mapping and Locating the Source

S1 S2

Tholakanahalli V, Bertog S, Roukoz H & Shivkumar K: Catheter Ablation Of Ventricular Tachycardia Using Intracoronary Wire Mapping And Coil Embolization: Description Of A New Technique. Heart Rhythm 2013;10:292-296

A NEUROINTERVENTIONAL INVENTION USED IN CARDIOLOGY!

INTRA-SEPTAL VT : MAPPING AND ABLATION

ECGI: Surface ECG combines with CT imaging to produce 3D maps of electrical activity on the surface of the human heart.

Shivkumar K , Narayan S M Sci Transl Med 2011;3:98fs2-98fs2

Software1. PVC selection

2. Patient specific models

3. Pkinect camera 

4. Register electrodes with torso model

5. Localization of the cardiac isochrones

Cardiac Isochrone Positioning System CIPS

ECG recorder

CT/MRI

Hardware

cameraimage

DICOM

ECG

Input Data Cardiac Isochrone Positioning System

Peter Van Dam PhD

CASE PRESENTATIONS• 52 year old female with monomorphic PVC’s and cardiomyopathy but no

evidence of scar on ceMRI

• 22 year old college student resuscitated from sudden death with monomorphic PVC’s

• 62 year old male post MI EF of 30% with syncope & VT storm

• 32 year old male with ‘ARVC’ (previous failed ablation) presents with incessant VT (multiple morphologies)-received 160 shocks (ICD-battery exhausted-skin burns)-intubated sedated-unstable death is imminent

Bradfield J, Homsi M, Shivkumar K and Miller JM: Coupling Interval Variability Differentiates Ventricular Ectopic Complexes Arising In The Aortic Sinus Of Valsalva And Great Cardiac Vein From Other Sources: Mechanistic And Arrhythmic Risk Implications. JACC 2014;63:2151-2158

LOOK AT COUPLING INTERVAL OF PVC’s CLOSELY! LOCATION AND RISK STRATIFICATION

Cardiac events (syncope, cardiac arrest, PMVT) were more common in the SOV/GCV vs the RV/LV group (7/27 [26%] vs 2/46 [4%], p<0.02)

• 52 year old female with monomorphic PVC’s and cardiomyopathy but no evidence of scar on ceMRI

• 22 year old college student resuscitated from sudden death with monomorphic PVC’s

• 62 year old male post MI EF of 30% with syncope & VT storm

• 32 year old male with ‘ARVC’ (previous failed ablation) presents with incessant VT (multiple morphologies)-received 160 shocks (ICD-battery exhausted-skin burns)-intubated sedated-unstable death is imminent

CASE PRESENTATIONS

Exit>QRSIsthmus

I

II

II

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Abl

V1

II

Ab

l

ON Abl: ON

1 23

45

1

2

3

1

4

5

5 Diastolicactivity

Systole

EpicardiumEndocardium

V1

4

SCHEMATIC OF VENTRICULAR TACHYCARDIA DUE TO A SCAR

Tung R, Boyle NG, Shivkumar K. Catheter ablation of ventricular tachycardia. Circulation. 2011;123(20):2284-2288

Rutherford SL, Trew ML, Sands GB, LeGrice IJ, Smaill BH. High-resolution 3-dimensional reconstruction of the infarct border zone: Impact of structural remodeling on electrical activation. Circulation Research. 2012;111:301-311

SCARS AND BORDER ZONES ARE COMPLEX! THE BAR FOR IMAGING

High‐densityVoltage Map

3D MRI Scar

EPI

RV

LV

ENDO

1.5mV

0.5mVTransmural Scar

MDLP

CON

LDLP

In-vivo MRI and EAM Correlation

Nakahara S, Vaseghi M, Ramirez RJ, Fonseca CG, Lai CK, Finn JP, Mahajan A, Boyle NG, Shivkumar K. Characterization of myocardial scars: electrophysiological imaging correlates in a porcine infarct model. Heart Rhythm. 8(7):1060-1067.

16

Conventional LGE  Wideband LGE

IMPROVED CARDIAC MRI IMAGING IN THE PRESENCE OF IMPLANTED DEVICES

Rashid S, Rapacchi S, Vaseghi M, Tung R, Shivkumar K, Finn JP, Hu P. Improved late gadolinium enhancement MR imaging for patients with implanted cardiac devices. Radiology. 2014;270:269-274

Stevens SM, Tung R, Rashid S, Gima J, Cote S, Pavez G, Khan S, Ennis DB, Finn JP, Boyle N, Shivkumar K, Hu P. Device artifact reduction for magnetic resonance imaging of patients with implantable cardioverter-defibrillators and ventricular tachycardia: Late gadolinium enhancement correlation with electroanatomic mapping. Heart Rhythm. 2014;11:289-298

17IMPROVED CARDIAC MRI IMAGING IN THE PRESENCE OF IMPLANTED DEVICES

Rashid S, Rapacchi S, Vaseghi M, Tung R, Shivkumar K, Finn JP, Hu P. Improved late gadolinium enhancement MR imaging for patients with implanted cardiac devices. Radiology. 2014;270:269-274

Stevens SM, Tung R, Rashid S, Gima J, Cote S, Pavez G, Khan S, Ennis DB, Finn JP, Boyle N, Shivkumar K, Hu P. Device artifact reduction for magnetic resonance imaging of patients with implantable cardioverter-defibrillators and ventricular tachycardia: Late gadolinium enhancement correlation with electroanatomic mapping. Heart Rhythm. 2014;11:289-298

Tung R, Mathuria N, Michowitz Y, Yu R, Buch E, Bradfield J, Mandapati R, Wiener I, Boyle N, Shivkumar K. Functional pace-mapping responses for identification of targets for catheter ablation of scar-mediated ventricular tachycardia. Circ Arrhythm Electrophysiol. 2012;5(2):264-272.

UCLA PROTOCOL FOR SUBSTRATE BASED AND ACTIVATION BASED MAPPING STRATEGIES FOR CATHETER ABLATION OF VENTRICULAR TACHYCARDIA

ELECTRICAL HOMOGENIZATION OF VENTRICULAR SCAR BY CATHETER-BASED DELIVERY OF COLLAGENASE

Yagishita D, Ajijola A, Vaseghi M, Nsair A, Zhou W, Yamakawa K, Tung R, Mahajan A and Shivkumar K. Electrical Homogenization Of Ventricular Scar By Application Of Collagenase: A Novel Strategy For Arrhythmia Therapy. Circulation Arrhythmias & Electrophysiology 2013;6:776-783

• 52 year old female with monomorphic PVC’s and cardiomyopathy but no evidence of scar on ceMRI

• 22 year old college student resuscitated from sudden death with monomorphic PVC’s

• 62 year old male post MI EF of 30% with syncope & VT storm

• 32 year old male with ‘ARVC’ (previous failed ablation) presents with incessant VT (multiple morphologies)-received 160 shocks (ICD-battery exhausted-skin burns)-intubated sedated-unstable death is imminent

CASE PRESENTATIONS

VT patient presentation:Medical and ICD management

Catheter Ablation of VT

Post-ablation management

Cardiac Electrophysiology

Discharge and follow-up care

Intensivists, Heart Failure Specialists, &

Anesthesiologists

Cardiac Anesthesiologists

Intensivists, Heart Failure Specialists, CT

surgeons

Primary Care & Heart Failure Specialists

Cardiac Electrophysiology

Cardiac Electrophysiology

Cardiac Electrophysiology

Tung R, Shivkumar K. Integrated care for management of ventricular arrhythmias: Can a specialized unit and catheter ablation improve mortality? Circulation 2013;127:1354-1356

UCLA Cardiac Arrhythmia CenterInterventional Management of Complex Arrhythmias and

Neurocardiology Program:

Mahajan A, Moore J, Cesario DA, Shivkumar K. Use of thoracic epidural anesthesia for management of electrical storm: A case report. Heart Rhythm. 2005;2:1359-1362

VT-VF STORM- CLINICAL COURSE

Heart Rhythm 2005; (2)12:1359 1362

Thoracic Epidural Delivery of 0.25% Bupicavaine at T1-T2 Interspace: Fluroscopic view of contrast injected via epidural catheter

Heart Rhythm 2005; (2)12:1363-1364

Early stage AIC++

Early stage AIC

Late stage AIC

Late stage AIC+

PERFUSION FDG METABOLISM

normal

normal

defect mismatch

defect mismatch

hilaruptake

peritracheal/ hilaruptake

PET-CT

Systemic inflammation+

Localized inflammation+

VALUE OF PET IMAGING: ‘CARDIAC INFLAMMATION’

Bauer B, Tung R, Bradfield J, Auerbach M, Schelbert H, Buch E, Vaseghi M, Fujimura O, Mandapati R, Lynch J, Boyle N, Shivkumar K: Ventricular Arrhythmias Due To Isolated Cardiac Sarcoidosis And Arrhythmogenic Inflammatory Cardiomyopathy (AIC) Identified By Abnormal Positron Emission Tomography In Patients With Idiopathic Cardiomyopathy Heart Rhythm 2014; 5(S):S29

RV

LV

RVLV

Hilar LN

PeritrachealLN

NH3

Post-Steroid therapyx 8 wks

Bauer B, Tung R, Bradfield J, Auerbach M, Schelbert H, Buch E, Vaseghi M, Fujimura O, Mandapati R, Lynch J, Boyle N, Shivkumar K: Ventricular Arrhythmias Due To Isolated Cardiac Sarcoidosis And Arrhythmogenic Inflammatory Cardiomyopathy (AIC) Identified By Abnormal Positron Emission Tomography In Patients With Idiopathic Cardiomyopathy Heart Rhythm 2014; 5(S):S29

LIMITS OF CURRENT CATHETER BASED THERAPY OF THE SUBSTRATE

• MMVT Circuits Are Deep Within Scar: ICM >NICM

• Scar Border Zones Are Critical: NICM ±

• Late potentials an ‘electrical footprint’: ICM>NICM

• Clinical Imaging Is Providing New Insights

• Mapping Techniques Have Greatly Improved

• Epicardial vs Endocardial Scar: NICM>ICM

• Interplay Between Structural VT And Functional Components: NICM possibly> ICM

NE

ACh

Spinal Cord

Thoracic

T1-T4 RSG

LSG

WHERE TO NEXT? A ‘HIGHER’ LEVEL-THE NEURAXIS

MACRO REENTRY

FOCAL VF

FUNCTIONAL ARRHYTHMIAS/HEART FAILURE

Circulation. 2010;121(21):2255-2262.

Bourke T, Vaseghi M, Michowitz Y, Sankhla V, Shah M, Swapna N, Boyle NG, Mahajan A, Narasimhan C, Lokhandwala Y, Shivkumar K. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121(21):2255-2262

Ajijola OA, Lellouche N, Bourke T, Tung R, Ahn S, Mahajan, Shivkumar K: Bilateral Cardiac Sympathetic Denervation For The Management Of Electrical Storm JACC 2012;59(1):91-92

Vaseghi M, Gima J, Kaanan C, Ajijola O, Marmureanu A, Mahajan A, Shivkumar K. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: Intermediate and long term follow up. Heart Rhythm. 2014;11:360-366

Lower ½ LSG 

T2T3T4

Thoracic ganglia

2 cm

Deflated lung

1st rib2nd rib

3rd rib

4th rib

Sympathetic chain

A B

C

Anatomy and histology of left sympathetic chain

Bourke T, Vaseghi M, Michowitz Y, Sankhla V, Shah M, Swapna N, Boyle NG, Mahajan A, Narasimhan C, Lokhandwala Y, Shivkumar K. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121(21):2255-2262.

Complete Re

spon

se (%

)

P < 0.05

P < 0.05

Bourke T, Vaseghi M, Michowitz Y, Sankhla V, Shah M, Swapna N, Boyle NG, Mahajan A, Narasimhan C, Lokhandwala Y, Shivkumar K. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121(21):2255-2262

Ajijola OA, Lellouche N, Bourke T, Tung R, Ahn S, Mahajan, Shivkumar K: Bilateral Cardiac Sympathetic Denervation For The Management Of Electrical Storm JACC 2012;59(1):91-92

Vaseghi M, Gima J, Kaanan C, Ajijola O, Marmureanu A, Mahajan A, Shivkumar K. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: Intermediate and long term follow up. Heart Rhythm. 2014;11:360-366

CARDIAC SYMPATHECTOMY FOR VT & VF INTERMEDIATE AND LONG TERM FOLLOW-UP: NORTH AMERICAN (UCLA) SERIES

STRUCTURE -FUNCTION INTERPLAY AND SCD

Higher Centers

Afferent signals Efferent

signals

CARDIO-NEURAL MAPPING

Autonomic Control!

Bodh Gaya, India

Cardiomyopathy & Transplantation:Gregg C. Fonarow MDTamara Horwich MD

Daniel Cruz MDArnold Baas MDMario Deng MD

Ali Nsair MD

ACHD:Ravi Mandapati MD

Jamil Aboulhosn MDPamela Miner RN NP

Cardiac Surgery:Hillel Laks MD

Murray Kwon MDRichard Shemin MD

Peyman Benharash MDCurtis Hunter MD

Jeffrey L. Ardell PhD, DirJ. Andrew Armour MD PhD

John Tompkins PhDEileen So BS

EP Nurse Practitioners:Shelly Cote RN MN NP

Jean Gima RN MN NP Geraldine Pavez RN MN NPResearch Administration:

Julie M. Sorg RN MSNHealthy Hearts ProgramSahib Khalsa MD PhD

Radiology:J. Paul Finn MD PhDStephen J. Kee MDJohn Moriarty MDStefan Ruehm MD

Administrative:Susana MoralesCarmen Mora BS

Tamika L. JeffersonJulie Ramirez BSHealth System:

Laura Brandsen-Yost MSHAErick Ascencio CVT

Center DirectorKalyanam Shivkumar MD PhD

Co-DirectorsNoel G. Boyle MD PhDAman Mahajan MD PhD

Specialized Program for AFEric F. Buch MD, MS, Dir

Specialized Program for VTRoderick H. Tung MD, DirImplanted Devices ClinicOsamu Fujimura MD, Dir

Cardiac EP, UCLA Olive ViewJason S. Bradfield MD, Dir

Clinical & Translational ResearchMarmar Vaseghi MD MS, Dir

West Los Angeles-VAMC:Zenaida Feliciano MD, Dir

Malcolm Bersohn MDJanet Han MD

Electrophysiology Faculty:Olujimi A. Ajijola MD PhD

Carlos Macias MDRavi Mandapati MDEP Fellows/trainees:

Tahmeed Contractor MDJorge Romero MD

Yuliya Krokhaleva MDKeijiro Nakamura MD PhD

Tadanobu Irie MD PhDUna Buckley MDDavid Hamon MD

Pradeep Rajendran BS (MSTP/PhD)Ray Chui BS (MCIP/PhD)

Echocardiography:Barbara Natterson MD

Aman Mahajan MD PhDCardiac Anesthesia:

Komal Patel MDJ. Schwarzenberger MD

Jonathan Ho MDJason Chua MD

Ryan Crowley MDAli Salehi MD

Coach John R. Wooden

1910-2010