1. Ventricular Tachycardia , Lin Yenn-Jiang MD. Chen Shih-Ann MD. April 24, 2011 Advanced EP training, THRS St. Jude Medical, TaipeiDivision of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan

2. Experience of VT EPS/ABL in Taipei VGH 2000-2010Outflow tract VT : 121 : 61%Fascicular VT : 24:12%ARVC :18: 9%CAD : 18: 9%DCM : 8: 4%

3. P=0.007Survival curve of VT patients (N=200) Fascicular VT RVOT ARVC CPVT, idiopathic VF Ischemic VT DCM

4. How to Map VTMapping Basic electrophysiologic study Pace mapping Activation mapping Electroanatomic mappingAblation: RV, LV, and Epicardium

5. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT

6. Outflow Tract Ventricular Tachycardia (OT-VT)VT arises from the right ventricular outflowtract (RVOT-VT, left ventricular outflowtract (LVOT-VT), aortic cusps (Cusp VT),and from the pulmonary artery (PA VT)OT-VT tend to occur in the absence ofstructural heart disease and are focal inorigin, the 12-lead ECG recorded duringVT is a precise localizing tool.

7. Clinical Features of RVOT-VTRVOT VT constitutes 75% of all patientswith outflow tract VTRVOT VT is more common in females 30-50 years old.Symptoms include palpitations, dizziness,atypical chest pain, and syncope.Exercise testing reproduces the patientsclinical VT 25 to 50% of the time.

8. Mechanism of RVOT-VTMost forms of RVOT VT are sensitive toadenosineMost likely mechanism is catecholaminemediated DAD and triggered activity.Mediated by the activation of cyclic AMP.Can be induced in the EP lab withisoproterenol, aminophylline, atropine, andrapid burst pacing but rarely withprogrammed ventricular extrastimuli.

9. 1. Important overlapping nature of the outflow tract course!2. RVOT and PA lie anterior and to the left of the LVOT and aorta.

10. RVOT VTIIIIIIaVRaVLaVFV1V2V3V4V5V6

11. RVOT VT morphology

12. Pulmonary Artery VT

13. How to D/D RVOT and VT with ASC in origin

14. Cross over of RVOT & LVOT region I: biphasic, V1 :W L R I: positive L V1 :RS R AP view Superior view David Callans JCE 2009

15. Aortic Cusp VT Morphology

16. LVOT and Aortic Cuspid VTVT arising from the LVOT shares similarcharacteristics to the RVOT VT because of acommon embryonic origin.ECG: LBBB with inferior axis with small R-waves in V1 and early precordial transition(R/S 1 by V2 or V3) or RBBB morphology withinferior axis and S-wave in V6.Aortic cusp VT accounts for up to 21% ofidiopathic VT.More commonly arises from the LCC, than theRCC and rarely arise from the NCC.

17. Tabatabaei and Asirvatham. Circ EP 2009;2:316-326

18. LVOT VT Morphology

19. Mapping Tool for OT-VTECG morphology:Could be non-induciblePacing morphologycould be large area 2 cm2: different chamber, scar, orepicardium,Activation mapMore accurate: remain unsuccess: more mapping sites,epicardium, different energy sources,

20. Spontaneous PVC Pace Mapping Taipei VGH 2010

21. PVCDisappearanceJustAfterRF

22. Schema of the Ventricular Arrhythmia Origin, Breakout Site, and Preferential Conduction From the LCC Origin to the RVOT or Left Ventricular Septum T. Yamada, et al JACC, 2007, Vol. 50, No. 9: 884-91

23. DifficultyinPaceMappinginRVOTTWithScarA VT PM 1 PM 2 B RVOT 2 1 Septal wall Anterior wall Free wall Taipei VGH 2010

24. Requirement of NCM for VT mappingPacing mapping may not sensitive tolocate the sites of foci in certain patientswith focal VT, in the presence of largescar area.VT could be non-sustained and unstable.It is difficult to map the entire chamberOne beat analysis of dynamic substrate byNCM may be useful to treat these patients.

25. EnsiteArrayLocation Taipei VGH 2010

26. RVOT VPC form the LVZ border(Higa S: University of the Ryukyus, Okinawa, Japan) 2010 Taipei VGH

27. Conclusions Carefully ECG interpretation and EP study to localize the optimum ablation site for VT. Usually not life threatening, and could be treated conservatively. 3D mapping system can be helpful (activation map or substrate map), but correct chamber, far- field sensing, preferential conduction need to be considered.

28. OutlinesOutflow tract VTRV related VT and ARVCFascicular VTSubstrate VT

29. RVOT VTIIIIIIaVRaVLaVFV1V2V3V4V5V6

30. Idiopathic RVOT-TRight ventricular outflow tract tachycardia(RVOT-T) represents up to 10% of all ventriculartachycardias (VTs), and is considered as abenign disease.Symptoms: Ranging from none to palpitations,lightheadedness, dyspnea, or syncope.Arrhythmias: Frequent isolated PVCs, bursts ofnonsustained VT, or sustained tachycardia oftenfacilitated by catecholamines or exercise.Ablation: Acute success rate of focal ablation ofRVOT-T is 6597% with rare complications.

31. ARVC

32. Arrhythmogenic RV DysplasiaCardiomyopathy begins in RV with poor contractilefunction and dilatation, progresses to LV finally.Histology: RV muscle becomes replaced by adiposeand fibrous tissue.Arrhythmia: Re-entrant Type (scarring & latePotentials) with LBBB type ECG;ECG: Diffuse T wave inversion over precordial leads,and Epsilon Wave.Ablation: The effect of catheter ablation istemporizing, 1/3 epicardium, mostly reentry.Implanted cardioverter defibrillator (ICD) is the onlyreliable therapy for sudden cardiac death.

33. Task Force Criteria TF(Definite+) ifmeet2majoror1major2minorcriteria McKenna et al. 1994, BMJ

34. Long-term OutcomeMean follow-up period 23 28 months (0.3 127) Cumulative Incidence Cumulative Incidence TF (-), 3.1% TF (-) : 14% TF (+) , 7.4% TF (+): 36%: P=0.511 P=0.019 Follow-Up Duration Follow-Up Duration All Cause Malignant Mortality arrhythmias

35. Conclusions Positive TF criteria is important to diagnose ARVC/D and is specific to detect the future VF/ICD implantation/ CV mortality Malignant ventricular arrhythmia and late recurrences may occur in patients with mild or atypical form of arrhythmogenic RV cardiomyopathy.

36. Posterior Fascicular VT

37. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT

38. Diastolic potential & Purkinje potential

39. Posterior Fascicular VT

40. Where to TargetDiastolic potential (P1) in themidseptum of LV. P1-QRS=28-130 msecIf P1 could not be identified, target thefused and earliest Purkinje potential(P2)Successful ablation revealed P1 duringSR could be a marker of successfulablation.

41. OutlinesOutflow tract VTARVCFascicular VTSubstrate VT

42. Structure heart related VT BBRT Ischemic heart disease (most common): mostly Endocardium ARVC: Epi/Endo Non-ischemic cardiomyopathy: Epi/Edno Tetralogy of Fallot and other post operation patients: Endo

43. Substrate VTIdentification of the critical ventricleto be targeted (voltage mapping).Identify the location of the scar(bipolar voltage 2 mV, < 70 msec, amplitude/duration70% 30-70% 40 msec: isthmus Entrainment mapping: Concealed entrain, with PPI=TCL Outer loop vs. inner loop Critical isthmus, > 40 msec, < 70% of S-QRS, > 22% of S-QRS interval Substrate mapping: Scar mapping

49. Case 1 Ventricular Tachycardia RV ICD Lead Pacing

50. Bi-Ventricular Voltage Map LVZ LVZ LVZ Ablation site Lin YJ et al. HRS abstract 2009

51. Ischemic LV VT---Case 1The important to identify chamber to ablate RVOT Septum LV apex ICD Lead Lin YJ et al. HRS abstract 2009

52. Lin YJ et al. HRS abstract 2009

53. IschemicLVVTCase2TheimportanttoidentifytheLVZandexitsite Tsai WC et al. JCE in revision, 2010

54. Case:IschemicLVVTTheimportanttoidentifytheLVZandexitsite Abnormal Substrate Entrainment Exit, entrance site Diastolic potential Tsai and Chen, Circ J, 2011

55. Voltage Map during SR (DSM 30%) Taipei VGH 2010

56. RVOT-T Patient Voltage of SR Spectral Analysis Activation of VT 3.5 cm from PV Successful site septum Free wall Eg during SRScar in the free wall site

57. ConclusionsOutflow tract VT is the commonest form ofidiopathic VT.ECG morphology is important for localization offocal VT and exit site of substrate VT before 3 Dmapping.Pacing mapping may not sensitive to locate thesites of foci in certain patients with focal VT, inthe presence of large scar area.Substrate mapping and entrainment mappingare important for the substrate VT.