Case Presentation: Walking through a case of epicardial VT ablation Kalyanam Shivkumar, MD PhD 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 (some licensed to Epic Medical Inc by University of California) Epicardial Interventions 2014 • • • • • • • • Catheter Ablation of VT (established) Catheter Ablation of SVT (established) Catheter Ablation of AF* LAA Snares (established) Epicardial Pacing* Epicardial Defibrillator Lead Placement* Tissue Engineering** Percutaneous VAD’s*** *Feasible, **Experimental, ***Possible CASE PRESENTATION • 73 year old gentleman with a history of ischemic cardiomyopathy EF 15-20%, s/p BIV-ICD presenting with multiple ICD shocks. • Patient had monomorphic VT at a TCL 395 ms (155 bpm) despite amiodarone, mexilitine, and sotalol. • Patient had a EPS/RFA for VT two years prior with a large inferior LV and another scar located superior/anterior LV on electroanatomic mapping. Encircling lesions of these two areas were done with a line connecting the two scars. CASE PRESENTATION-contd • Patient had more shocks after this with a drop in EF to 20%, had coronary angiography that showed 50% LAD and 70% distal RCA, no intervention done. • A repeat EPS/RFA was done a year later with the same scar seen, ablation re-enforced the same lesion sets. • He has had more ICD shocks for monomorphic VT TCL 345 ms (175 bpm) • Referred for combined epi-endo mapping and ablation. Epicardial Case • • • • • Pre-procedure work-up Pericardial Access Mapping Strategy Ablation Issues Follow up Pre-procedure • Indication • Approach • Coronary Anatomy-allows merge (but not an alternative for pre-ablation imaging) • Substrate Imaging • General issues (thoracic surgery, coagulopathy, chest wall anatomy) Flow Chart: Suggested Approach to Epicardial Access/Ablation 1. ECG suggest Epicardial VT exit site A B NO 2. Prior unsuccessful Endocardial Ablation NO 3. Define SCAR location with CE imaging: subendocardial or mid-myocardial scar YES Consider obtaining Epicardial YES Access for Mapping YES (and NO 4. Consider likelihood of Epicardial circuit for Underlying Substate: C Ablation) HIGH LOW Perform endocardial mapping and ablation first C B A ECG Criteria 1) pseudo-delta >34 ms 2) intrinsicoid deflection time (v2) >85 ms 3) Shortest RS complex >121 ms ECG Criteria for NICM 1) Absence of inferior Q wave Probability of Epicardial Focus Normal 6% 2) pseudo-delta ≥75 ms ICM 16% 3) MDI >0.59 NICM 35% ARVD 41% Other CM 18% 4) Presence of Q wave in lead I 4) ORS duration >211 ms Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology: Circulation 2012;126: 1752-1769 IMPROVED CARDIAC MRI IMAGING IN THE PRESENCE OF IMPLANTED DEVICES Conventional LGE Wideband LGE 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 cardioverterdefibrillators and ventricular tachycardia: Late gadolinium enhancement correlation with electroanatomic mapping. Heart Rhythm 2014 (in press, available online) 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 IMPROVED CARDIAC MRI IMAGING IN THE PRESENCE OF IMPLANTED DEVICES 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 (in press, available online) 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 Epicardial Case • • • • • Pre-procedure work-up Pericardial Access Mapping Strategy Ablation Issues Follow up THE PERICARDIAL SPACE ALLOWS UNIQUE ACCESS TO THE HEART McAlpine WA Collection: copyright UCLA Cardiac Arrhythmia Center: used with permission SCHEMATIC OF PERICARDIAL SINUSES AND ACCESS TO VARIOUS EPICARDIAL REGIONS VIA THE PERICARDIAL SPACE Sinus Sheath in front of Great Arteries A RCA HRA HIS ENDO Anterior Access: Lateral Tricuspid annulus Anterior Right Ventricle Aorta SVC PA RV CS EPI B Halo Aorta RSPV LAA LSPV LIPV RIPV PA Inferior/Posterior/Lateral Access areas Lateral mitral annulus LAA LV ant and lat wall Posterior left atrium (via oblique sinus) Diaphragmatic surfaces of RV and LV Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology: Circulation 2012;126: 1752-1769 C PERICARDIAL ACCESS SAGITTAL VIEW Sternum RV Pericardial Space Needle direction Diaphragm Inferior RV Liver Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology: Circulation 2012;126: 1752-1769 Anterior Liver PERICARDIAL ACCESS CROSS SECTIONAL VIEW Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology: Circulation 2012;126: 1752-1769 EPICARDIAL ACCESS NEEDLES AND LANDMARKS FOR NEEDLE ENTRY RV Curved end faces Heart Liver Inferior Anterior Direction of Needle Entry Open end away from Heart toward right inferior quadrant 3-6 O'clock viewed from caudal view Boyle NG & Shivkumar K: Epicardial Interventions in Electrophysiology: Circulation 2012;126: 1752-1769 Dangers of Pericardial Access • • • • • RV perforation Pericardial bleeding Liver Injury Abdominal Bleeding Entry into left pleural space ELECTROANATOMIC MAPPING AIDED EPICARDIAL ACCESS Bradfield J, Tung R, Vaseghi M, Morarty JM, Boyle NG, Buch E, Mandapati R, Shivkumar K: Use Of Electroanatomical Mapping To Guide Percutaneous Epicardial Access: A Novel Application To Improve Safety. J Cardiovasc Electrophysiol. 2012;23:1185-1190 Inadvertent hepatic access Video of Direct Visualization Epicardial Access: Issues ‘en route’ Bradfield J, Vaseghi M, Mathuria N, Boyle N, Shivkumar K : Direct visualization Epicardial Access (in preparation) STEP 1: STAIN PERICARDIUM STEP 2: PUNCTURE PERICARDIUM STEP 3: ADVANCE WIRE (ENSURE PERICARDIAL LOCATION LAO VIEW) STEP 4: PERICARDIOGRAPHY-ENSURE THERE ARE NO ADHESIONS Pericardial adhesions PRE-ACCESS FLUOROSCOPY IN OUR PATIENT Epicardial Case • • • • • Pre-procedure work-up Pericardial Access Mapping Strategy Ablation Issues Follow up STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s 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;5:264-272 STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s Nakahara S, Tung R, Ramirez R, Gima J, Wiener I, Mahajan A, Boyle NG and Shivkumar K. Distribution Of Late Potentials Within Infarct Scars Assessed By Ultra High Density Mapping. Heart Rhythm 2010;7(12):1817-1824 Tung R, Nakahara S, Maccabelli G, Buch E, Wiener I, Boyle NG, Carbucicchio C, Bella PD, Shivkumar K. Ultra high-density multipolar mapping with double ventricular access: a novel technique for ablation of ventricular tachycardia. J Cardiovasc Electrophysiol. 2011;22(1):49-56 STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s Clinical VT STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s Rapid termination of VT1 STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Abl II V5 Abl 500 520 520 STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Abl STRATEGY FOR SUBSTRATE BASED MAPPING AND ABLATION FOR STABLE AND UNSTABLE VT’s VT Entrance VT Exit Exit Exit Tung R, Mathuria N, Michowitz Y, Yu R, Buch E, Bradfield J, Mandapati R, Wiener I, Boyle N, Shivkumar K. Circ Arrhythm Electrophysiol 2012; 5: 264-272.-272. VT1 pacemap LP for VT1 pacemap VT 3 Perfect pace map for VT3 same scar area as VT1 more apical Nakahara S, Tung R, Ramirez R, Gima J, Wiener I, Mahajan A, Boyle NG and Shivkumar K. Distribution Of Late Potentials Within Infarct Scars Assessed By Ultra High Density Mapping. Heart Rhythm 2010;7(12):1817-1824 SCARS SHOW ‘CHANNELS’ OF CONDUCTION Tung R, Mathuria NS, Nagel R, Mandapati R, Buch EF, Bradfield JS, Vaseghi M, Boyle NG & Shivkumar K: Impact Of Local Ablation On Inter-connected Channels Within Ventricular Scar: Mechanistic Implications For Substrate Modification. Circ Arrhythm Electrophysiol. 2013;6:1131-1138 VT1 VT3 Epicardial Case • • • • • Pre-procedure work-up Pericardial Access Mapping Strategy Ablation Issues Follow up DISTINGUISING EPICARDIAL FAT FROM SCAR: LCX INFARCT MODEL Tung R, Nakahara S, Ramirez R. Lai C, Fishbein MC and Shivkumar K: Distinguishing Epicardial Fat From Scar: Analysis Of Electrograms Using High Density Electroanatomic Mapping In A Novel Porcine Infarct Model. Heart Rhythm 2010;7(3):389-395 DISTINGUISING EPICARDIAL FAT FROM SCAR: INSULATING EFFECT OF FAT Tung R, Nakahara S, Ramirez R. Lai C, Fishbein MC and Shivkumar K: Distinguishing Epicardial Fat From Scar: Analysis Of Electrograms Using High Density Electroanatomic Mapping In A Novel Porcine Infarct Model. Heart Rhythm 2010;7(3):389-395 CORONARY ARTERIOGRAPHY MEDIASTINAL NERVES Pai RK, Boyle NG, Child JS, Shivkumar K. Transient left recurrent laryngeal nerve palsy following catheter ablation of atrial fibrillation. Heart Rhythm. 2005;2(2):182-184 PHRENIC PROTECTION Buch E, Vaseghi M, Cesario DA, Shivkumar K. A novel method for preventing phrenic nerve injury during catheter ablation. Heart Rhythm. 2007;4(1):95-98 Ablation Site: Pacing via ablation catheter post-balloon inflation Buch E, Vaseghi M, Cesario DA, Shivkumar K. A novel method for preventing phrenic nerve injury during catheter ablation. Heart Rhythm. 2007;4(1):95-98 UCLA SANTA BARBARA • SANTA CRUZ Buch E, Vaseghi M, Cesario DA, Shivkumar K. A novel method for preventing phrenic nerve injury during catheter ablation. Heart Rhythm. 2007;4(1):95-98. Epicardial Case • • • • • Pre-procedure work-up Pericardial Access Mapping Strategy Ablation Issues Follow up Follow up-finishing case Closing pericardiogram and draining space Leaving drain in vs not Steroids/colchicine Monitor abdomen and follow up echo prior to discharge Anlagesics CASE FOLLOW UP • 100 cc of slightly discolored fluid drained at end of case, no drain left in • Patient discharged 48 hours post ablation with optimized heart failure medications • At 2 years of follow up no-ATP or shocks • On heart failure medications and amiodarone, other anti arrhythmic drugs were discontinued post ablation Conclusions • Need for pericardial access will increase • More patients can benefit by these procedures • New technology is needed for wider application Cardiomyopathy & Transplantation: Gregg C. Fonarow MD Tamara Horwich MD Daniel Cruz MD Arnold Baas MD Ann Hickey MD Mario Deng MD Ali Nsair MD ACHD: Ravi Mandapati MD Jamil Aboulhosn MD Pamela Miner RN NP Cardiac Surgery: Hillel Laks MD Murray Kwon MD Richard Shemin MD Peyman Benharash MD Curtis Hunter MD Echocardiography: Barbara Natterson MD Aman Mahajan MD PhD Cardiac Anesthesia: Komal Patel MD J. Schwarzenberger MD Jonathan Ho MD Jason Chua MD Ryan Crowley MD Ali Salehi MD Center Director Kalyanam Shivkumar MD PhD Co-Directors Noel G. Boyle MD PhD Ravi Mandapati MD Aman Mahajan MD PhD Specialized Program for AF Eric F. Buch MD, MS, Dir Specialized Program for VT Roderick H. Tung MD, Dir Implanted Devices Clinic Osamu Fujimura MD, Dir Cardiac EP, UCLA Olive View Jason S. Bradfield MD, Dir Clinical & Translational Research Marmar Vaseghi MD MS, Dir Neurocardiology Research Jeffrey L. Ardell PhD, Dir J. Andrew Armour MD PhD Eileen So BS EP Nurse Practitioners: Shelly Cote RN MN NP Jean Gima RN MN NP Geraldine Pavez RN MN NP Research Administration: Julie M. Sorg RN MSN Radiology: J. Paul Finn MD Stephen J. Kee MD John Moriarty MD Stefan Ruehm MD West Los Angeles-VAMC: Zenaida Feliciano MD, Dir Administrative: Malcolm Bersohn MD Michelle Betwarda BS MHA Janet Han MD Alissa Diaz BS Electrophysiology Faculty: Susana Morales William L Discepolo II MD Carmen Mora BS Arby Nahapetian MD Tamika L. Jefferson EP Fellows/trainees: Jacquelyn Barnhill Olujimi A. Ajijola MD PhD Julie Ramirez BS Carlos Macias MD Health System: Keijiro Nakamura MD PhD Laura Brandsen-Yost MSHA Tadanobu Irie MD PhD Erick Ascencio CVT Steven Stevens MD Daigo Yagishita MD PhD David Hamon MD Coach John R. Wooden Pradeep Rajendran BS (MSTP/PhD) 1910-2010 Ray Chui BS (MCIP/PhD)