mapping and ablation in early repolarization syndromes · there are 2 phenotypes of early...
TRANSCRIPT
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Jacob Atié, MD, PhD, FESC
Prof of Cardiology Federal University of Rio de Janeiro
Director Arrhythmias Department
Clínica São Vicente [email protected]
What is New in Channelopathies and Purkinje Related Ventricular Arrhythmias?
Mapping and Ablation in Early Repolarization Syndromes
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Federal University of Rio de Janeiro
Presenter Disclosure Information
None
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Prevalence and Characteristics of Early Repolarization in
the CASPER Registry 100 ptCardiac Arrest Survivals with Preserved Ejection fraction Registry
At least 2 leads J point elevation
Derval et al. JACC 2011;58:722-8
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Prevalence and Characteristics of Early Repolarization in
the CASPER Registry
100 pt
Derval et al. JACC 2011;58:722-8
13/56 (23%)6/44 (9%)
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Prevalence and Characteristics of Early Repolarization in
the CASPER Registry
100 pt
Derval et al. JACC 2011;58:722-8
13/56 (23%)6/44 (9%)
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Role of the Purkinje Conducting System in
Triggering of Idiopathic VF
16 pt
RV purkinje Left purkinje
Haissaguerre et al. Lancet. 2002 Feb 23;359(9307):677-8.
12 – Purkinje
4 – muscular
Ablation
14 (88%)
no recurrence
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Mapping and Ablation of VF Associated with
Long QT and Brugada Syndromes
Haissaguerre et al. Circulation 2003;108:925-928
Left purkinje origin
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Long Term Follow-up of Idiopathic
Ventricular Fibrillationa Multicenter Study
Knecht et al. JACC 2009;54:522-8
6 Centers – 38pt
Triggering VPBs originated
Purkinje
Righ- 16 Left 14 Both 3
Myocardium 5 pt
During mean Fup 63 months
7/38 pt (18%) recurrence VF
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Epicardial Electrogram of the RVOT in Pt
with Brugada Syndrome Using an epicardial lead
5 Pt
Gide wire Conus branch – RCA
After IC AAD
all pt presented epi late potential
Nagase et al. JACC 2002;39:1992-5
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Epicardial Electrogram of the RVOT in Pt
with Brugada Syndrome Using an epicardial lead
5 Pt
Gide wire Conus branch – RCA
After IC AAD
all pt presented epi late potential
Nagase et al. JACC 2002;39:1992-5
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Prevention of VF in Brugada Syndrome by Catheter
Ablation Over the Anterior RVOT epicardium
9 pt recurrent VF
Nademanee et al. Circulation 2011;123:1270-79
Double annotation MAP
Longest
duration
Fractionated potentials
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Prevention of VF in Brugada Syndrome by Catheter
Ablation Over the Anterior RVOT epicardium
9 pt recurrent VF
Nademanee et al. Circulation 2011;123:1270-79
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7/9 – non inducible after
ablation
Follow-up 20 + 6 months
no VF recurrence
Prevention of VF in Brugadda Syndrome by Catheter
Ablation Over the Anterior RVOT epicardium
9 pt recurrent VF
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Insight into mechanism of Brugada Syndrome: Epicardial substrate
and modification during ajmaline testing
Sacher F. Heart Rhythm 2014;11:732-734
32 years man
VF – no trigger
Pentaray
ajmalinaFractionated potentials
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Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
14 pt
EKG clinic
EKG lab
(A) Although the coved type ECG Brugada
Brugada J. Circ EP 2015;8:1373-81
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Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Flecainide
Brugada J. Circ EP 2015;8:1373-81
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Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Brugada J. Circ EP 2015;8:1373-81
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Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Brugada J. Circ EP 2015;8:1373-81
Fractionated potential
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Brugada Syndrome Phenotype Elimination by
Epicardial Substrate Ablation
Without Flecainide
With Flecainide
PRE After ABlation Follow-up
Brugada J. Circ EP 2015;8:1373-81
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Coved type increasing during RF-Ablation
I
II
III
aVR
aVL
aVF
V1
V2
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ST Elevation during RF delivery
V2 progressively loose the
down-sloped shapeRF Start After few RF application
V1starts to change morphology
as well
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• Mean Fup: 22 + 16 months
• 25/30 pt (83% ) - free of VF recurrences and normal ECG
• Remaining 5 pt
• 2 pt continuous presence of ST elevation type I
• 3 pt with early repolarization
Long Term Outcome After Epicardial Ablation of Anterior
RVOT in Brugada Syndrome Pt
30 pt
Nademanee. HRS 2015
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Pappone C. Circ Electr 2017;10:e005053
135 pt with Brugada syndrome
63 pt ICD and VT-VF
72 pt inducible VT-VF
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32 y old, syncope induced VF
Pappone C. Circ Electr 2017;10:e005053
Homogenization
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Outcome
Follow up – 10 months
2 recurrence VF – new ablation
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Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
52 pt with Early repolarization and VF
Eletroantomical mapping: sinus and VF
RV, LV, endo and epi mapping – CardioInsight - 252 electrodes
Phenotype:
Group I: Late depolarization abnormality (with electrical substrate)
Grou II: No late repolarization (12 pt)
Ia: Brugada syndrome pattern (33 pt)
Ib: ERS without Brugada S. (7 pt)
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IB (with substrate no Brugada)
Early Repolarization Inferior leads
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
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IB (with substrate no Brugada)
Substrate with low voltageEarly Repolarization Inferior leads
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
Late depolarization abnormality
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Group II
No late potentials depolarization RV, LV, endo ,epi
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
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Group II
No late potentials depolarization RV, LV, endo ,epi
Nademanee K, Haissaguere M et al, Circulation 2019;140:1477-90
No late potentials or low conduction
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Group I A (Brugada Syndrome)
Fractionated late
Potencials
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Group I A (Brugada Syndrome)
Rotational activity
during VF
Focal activity
during VF
Fractionated late
Potencials
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Focal and Reentry activity – FV Correlates
with fractionated late potencials
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Group I A (Brugada Syndrome)
Ablation
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Effect of Ablation in VF
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30 years old male
Previously healthy, no history of medication or drugs
Living donor for liver transplantation
During anesthesic induction – VF
More than 40 episodes
Morand, Atié ESC 2019
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30 years old male
Previously healthy, no history of medication or drugs
Living donor for liver transplantation
During anesthesic induction – VF
More than 40 episodes
Morand, Atié ESC 2019
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General anestesia, Amiodarone, Lidocaine, betabloker,
Ca Gluconate, Magnesium sulfate, Pacemaker,
Stellate ganglion block
Morand, Atié ESC 2019
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45ms
Morand, Atié ESC 2019
Catheter Ablation
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45ms
Morand, Atié ESC 2019
Catheter Ablation
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• Ablation for Idiopathic VF – target short couple VPB
from left and right Purkinje and RVOT.
Conclusions
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• Ablation for Idiopathic VF – target short couple VPB
from left and right Purkinje and RVOT.
• Ablation over anterior RVOT epicardium is effective
in preventing VF in Brugada Syndrome
Conclusions
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• Ablation for Idiopathic VF – target short couple VPB
from left and right Purkinje and RVOT.
• Ablation over anterior RVOT epicardium is effective
in preventing VF in Brugada Syndrome
• Disapearence of Brugada ECG pattern is associated
with no recurrence of VF episodes
Conclusions
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Conclusions:
In Brugada S. there is a relation between ECG
pattern, the extent of abnormal substrate and
VT/VF induction
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Conclusions:
In Brugada S. there is a relation between ECG
pattern, the extent of abnormal substrate and
VT/VF induction
There are 2 phenotypes of Early Repolarization
with and without late depolarization
abnormalities. Ablation is effective to treat
symptomatic pts. (substrate or triggers in the
purkinje sites)
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Thank you
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Epicardial RF Ablation- Homogenization
Case 2
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Epicardial Biopsy Surgical Ablation
Brugada Syndrome
5 pt
Nademanee. HRS 2015
Brugada Syndrome
Structural Normal
Heart?
Fibrosis
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