MID TERM RESULTS OF FOCAL VENTRICULAR ABLATION AT TAM DUC HEART HOSPITAL

MID-TERM RESULTS OF FOCAL VENTRICULAR ABLATION AT TAM DUC HEART HOSPITAL FROM APRIL 2014 TO SEPTEMBER 2016 Do Van Buu Dan, MD On behalf of EP team of Tam Duc Heart hospital BACKGROUND • Focal ventricular arrhythmia (VAs) is pretty common in clinical practice, originating from RVOT, LVOT, papillary muscle… • Clinical presentation varies from PVCs, nonsustained to sustained VT • Symptoms could be slightly symptomatic (palpitation, dizziness, shortness of breath) or presyncope/syncope • May even induce cardiomyopathy BACKGROUND (2) • Average effectiveness of medication is #50% • RCFA is effective for medication-refractory VAs with the successful rate up to 90% • The results of RCFA differs among centers in Vietnam Some reported successful rate only about 50% OBJECTIVES • Investigating the results of RFCA for 50 focal VA patients in Tam Duc Heart hospital from April 2014 to September 2016 • Identifying factors predicting success in mid-term follow-up Method • Between April 2008 and October 2016 • A total of 50 consecutive patients idiopathic focal VA have been enrolled Inclusion criteria: - Symptomatic VA refractory to at least one AAD - Asymptomatic PVC with PVC burden >20% total heart beats/Holter ECG - Arrhythmia-related cardiomyopathy Exclusion critera: VA associated with coronary disease, surgical scar, or Brugada syndrome EP study and mapping • After obtaining informed consent from patients, EPS was performed for all patients in the fasting and non-sedated state • Before the study, all AADs except amiodarone were discontinued for at least half-lives • In the absence of spontaneous VA, ventricular stimulation protocol was performed with or without Isoproterenol infusion (1–4 μg/min) EP study and mapping (2) • The localization of arrhythmogenic foci was performed conventionally or by using 3D mapping system (EnsiteNavX™, St Jude Inc., St Paul, MN, USA) • Activation mapping, defining the earliest activation (EA) signals, • And/or pace mapping by comparing the 12-lead QRS morphology of paced PVCs with clinical PVCs aiming for at least 11/12 leads matching Activation mapping EA = 32ms Pace mapping 11/12 match Conventional vs 3D mapping RESULTS (N=50) Ablation catheter • Non-irrigated 4mm • Irrigated 4mm • Non-irrigated 8mm 30 (60%) 14 (28%) (12%) RESULTS (N=50) Outcome • Acute success • Failed ablation 2014-2015 2016 • Complication • Follow-up duration (month) • Non-recurrent • Recurrent 44 (88%) (12%) 4/17 (23.5%) 2/33 (6%) 8.5 (3.1-11.6) 37/44 (84.1%) 7/44 (15.9%) Comparison between patients with and without recurrences (N=44) • • • • • • Non-recurrent (N=37) Age 44.2±12.9 Gender (Male %) 11(29.7%) Hypertension 10 (27%) Diabetes mellitus (10.8%) Dyslipidemia (16.2%) Smoking (2.7%) Recurrent (N=7) 29.7±12.5 (14.3%) (0%) (0%) (0%) (0%) P value 0.009 0.653 0.177 0.568 Comparison between patients with and without recurrences (N=44) Non-recurrent (N=37) Symptoms • Dyspnea • Palpitation • Chest pain • Dizziness • Syncope • Duration of Sx (year) 31 (83.8%) 25 (67.6%) 21 (56.8%) (21.6%) (10.8%) (2-6.5) Recurrent (N=7) P value (57.1) (85.7%) (28.6%) (28.6) (28.6%) (0.5-7) 0.138 0.654 0.232 0.649 0.238 0.228 Comparison between patients with and without recurrences (N=44) No recurrences (N=37) Holter recordings • PVC 24 (64.9%) • VT 13 (35.1) • % PVC/24 hours 23.8±9 Structural assessment Recurrences P value (N=7) (71.4%) (28.6%) 32.7±11 0.147 • LVEF (%) • LVEDD (mm) • LVESD (mm) 66.9±4.4 46.3±2.7 27.5±3.8 0.352 0.156 0.162 63.9±10.9 48.8±5.9 31.1±5.7 Comparison between patients with and without recurrences (N=44) No recurrences Recurrences P value (N=37) (N=7) Antiarrhythmic drugs used before catheter ablation • β-blocker 27 (73%) (100%) 0.177 • CCB • Flecainide • Amiodarone (2.7%) 15 (40.5%) (16.2%) (7.7%) (30.8%) (15.4%) 0.456 0.742 • Theophylline (8.1%) (0.0) Comparison between patients with and without recurrences (N=44) No recurrences Mapping systems • Conventional • Ensite NavX Ablation catheter • Non-irrigated 4mm • Irrigated 4mm • Non-irrigated 8mm Recurrences P value (N=37) (N=7) 27 (73%) (69.2%) 10 (27%) (30.8%) 25(67.6%) 10 (27.0) (5.4%) 4(57.1%) (28.6%) (14.3%) 0.676 Comparison between patients with and without recurrences (N=44) No recurrences (N=37) Recurrences P value (N=7) • VA origin RVOT 34 (91.9%) 13 (100%) Non-RVOT Multiple sites • VA_QRS duration(msec) (8.1%) (16.2%) 135.8±7.6 (0%) (7.7%) 133.3±6.9 0.558 0.660 0.419 Comparison between patients with and without recurrences (N=44) No recurrences (N=37) Mapping • EA time (msec) • Perfect pace map (12/12) Catheter ablation • RF current pulses • Ablation time (min) • Fluoroscopy time (min) • Procedure time Recurrences P value (N=7) 36.1±4.9 27 (72.9%) 30.7±4.7 (14.3%) 0.010 0.006 10 (8-18.5) 7.1±3.2 25.7±14.9 69.1±26.7 20 (10-25) 7.4±2.6 27.9±14.0 70.9±25.3 0.096 0.788 0.723 0.869 Kaplan-Meier Non-recurrent curve Perfect vs Non-perfect pace map ROC curve analysis • The optimal cutoff values for identifying nonrecurrent group were generated from receiveroperating characteristic (ROC) curves The earliest activation time (EA) was used for determining the cutoff value according to the greater area under the ROC curve • Cutoff values of EA ≥ 31.5ms could differentiate the non-recurrent group from recurrent group, as manifested by a sensitivity of 81% and specificity of 71% (AUC 0.79) CONCLUSIONS • RFCA is the treatment of choice for patients with VAs refractory to AADs • Procedure is pretty safe and effective • After 8.5 months FU, the rate of free-fromrecurrence was 84.1% • Obtaining EA ≥31.5ms or perfect pace map before applying RF energy to avoid recurrence Thank you for your attention ... delivered in a temperaturecontrolled mode at 60oC with pulse duration of 60 seconds; maximal power was 50 Watts for nonirrigated catheter and 30-35 Watts for irrigated catheter • If the VA was... vs 3D mapping RESULTS (N=50) Ablation catheter • Non-irrigated 4mm • Irrigated 4mm • Non-irrigated 8mm 30 (60%) 14 (28%) (12%) RESULTS (N=50) Outcome • Acute success • Failed ablation 2014-2015... Investigating the results of RFCA for 50 focal VA patients in Tam Duc Heart hospital from April 2014 to September 2016 • Identifying factors predicting success in mid- term follow-up Method •