EHRA educational review and preparatory course for accreditation examinationInvasive Cardiac Electrophysiology examination preparatory course

Ventricular arrhythmia 2 – idiopathic VT: ECG + intracardiac IECG Tracings - how to ablate?

Prof. Dr. M. Antz Oldenburg Heart Center, Germany

European Heart House Sophia-Antipolis, France

26th of February, 2011: 11:00 - 11:30

Matthias Antz

Complex anatomy of the outflow tracts

V1

Asirvatham SJ, JCE 2009;20:955-968

RCC LCC

RVOT

LVOT

Ant. RVOT

Post. RVOT

Right CC

Left CC

LVOT

Asirvatham SJ, JCE 2009;20:955-968

Angiography of aortic root

NCC RCC

LCC

LAD

CS

His

RAO 30°

Oblique course of aortic root !

L R

N

His

CS/GCV

Chun KRJ, …, Antz M, Herz 2007;32:226-232

Local potentials in the aortic cusps

RCC

-large V from RVOT -near NCC: small A from RAA or antsept TA

RCC

V A

LCC

-large V from RVOT or antsept TA -large A from LA or mitral anulus

LCC

NCC

V A

-smaller V from LVOT or antsept TA -large A from IAS: turn clockwiseLA turn counterclockwise RA

RV-pace

NCC

Mapping strategy if His early

His-Area

I

II

V1

Map1-2

Map3-4

Mapuni

His

10ms

I

27ms

Mapping-criteria

Right aortic cusp

II - Bipolar 21-26ms before QRS - Unipolar sign. later than bipolar V1 - Pacing only in 66% possible (?) - Distance to RCA: 7-12 mm

Map1-2

Mapuni

His

20020187

Mapping strategy if distal CS/GCV early

Left aortic cusp

Mapping-criteria - Bipolar 28-97ms before QRS - Unipolar sign. later than bipolar - Pacing only in 11% possible (?) - Distance to LM: 7-20 mm

Matthias Antz

• Angiography: Aortic root and coronary ostia – Intubation of left main coronary artery (?) – Monitoring of catheter movement during RF

– Cave: dislodgment of catheter into left main coronary artery

• RF ablation: settings for ablation – Target temperature: 55 °C – Maximal power: 30 Watt, 120 sec

• Definition of success: – No spontaneous or inducible VT / VES at end of study

– No clinical arrhythmia in Holter / exercise test

Outflow tract tachycardia: ablation in aortic root

Mapping criteria - Bipolar 15-26ms before QRS - Unipolar same timing as bipolar - perfect pacemap in 100%

Mapping and ablation in the LVOT (RSB-VT)

Settings for ablation - 4 mm electrode - Temp control 55°C - max. 30-40W - 60-120 sec

Matthias Antz

Retrospective analysis in 133 pts with idiopathic RVOT-VT (FU= 135 ± 68 months)

* Ventura et al, European Heart Journal 2007;28:2338-45

48/71 (68%)

X

Idiopathic Left Ventricular Tachycardia (ILVT)

Left superior axis: 90–95 % origin: left posterior fascicle

right inferior axis: 5–10 % origin: left anterior fascicle

Matthias Antz

ILVT- Components of reentry circuit

• Antegrade limb: slow conducting component (LV false tendon, degenerative Purkinje tissue, Mahaim-like fiber)

• Retrograde limb: fast conducting component (ventricular muscle, Purkinje network)

• Transition zone: (links the two components as well as the His-Purkinje system)

Matthias Antz

ILVT: Site of ablation – during VT

• Diastolic potential during VT

• Earliest Purkinje-potential during VT preceding ventricular activation (30–40 ms before QRS-complex)

Nakagawa et al 1993 / Wen et al 1994

CARTO Map of left ventricle during ILVT

Ouyang et al, Circulation 2002:105:462–469

Site A

Site B

Site C

Site D

Matthias Antz

Target site during sinus rhythm: • „earliest late potential“ earliest retrograde Purkinje Potential

Site of Ablation – during SR

Map of left ventricle during SR (ILVT patient) single DP

Site A

Site B

Site C Site D

RF applications: 1-3; Procedure: 262±45 min; Fluoro: 5.4±1.4 min Ouyang et al, Circulation 2002:105:462–469