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Usefulness of new imaging techniques to
identify complex arrhytmogenic substrates in
the ventricle
Venice Arrhythmias 2013
“SOLAECE Corner”
Gerardo Rodríguez Diez MD
National Medical Center “20 de Noviembre” ISSSTE.
México D.F.
SOLAECE Treasurer
NO CONFLICT OF
INTEREST TO
DECLARE
Key points
o Background
o Ablation targets
o New imaging techniques
• ICE
• ce-CMR

o Conclusion
Background
o Non structural heart disease (focal origin)
• Increase Automaticity
• Triggered activity (early or delayed
afterdepolarizations)

o Structural Heart disease (scar-related)
• Ischemic or no Ischemic
• Relative large reentry circuits
• Complex substrates around the fibrosis scars
or border zones
Ventricular Arrhythmias and Scar
• Critical anatomic substrates sustaining VA’s, shows different
degrees of fibrosis / scar (even in cases of focal origin)
*90% of sustained
VT’s are due to
reentry involving
an area of ventricular
scar.
10% remaining are
due to reentry
or automaticity
involving the
Purkinje system.
Pogwizd SM, et al. Circulation 1998. *Stevenson WG, Heart Rhythm 2013.
Usefulness of new imaging techniques
Targets for ablation
o Conduction channels (CC’s)
•
•

Bundles of viable myocardium inside scars that
become part of reentrant circuit during VT
Are located at any level of the myocardium wall
with variable thickness and a 3D- structure
VT ablation targets
o Electroanatomic maps (EAM)
•
•

Is a depiction of cardiac anatomy (through a color-coded
display of the intracardiac electrogam)
Areas of interest
•

reduce electrogram amplitude in voltage maps

o Normal Electrogram amplitude
• >1.5mV
o Border zone electrogram
• 0.5-1.5 mV
o Core scar
• < 0.5 mV
Catheter Ablation of reentrant VT
o Goal: Identification of critical isthmus of
conduction that is part of the reentrant
circuit
Conventional VT ablation limitations

o
o
o
o
o

Hemodynamic intolerance
Multiple changing morphologies
Hemodynamic collapse
Noninducible VT during EP testing
Recurrences (50-88%)

o Identification of the underlying substrate
using voltage mapping with 3D
reconstruction point by point
• It’s cumbersome
• Requires considerable skill
• It’s time consuming
Complex imaging techniques
o Rationale
•
•
•
•

Characterization of arrhythmogenic substrates
Direct guidance and characterization of ablation lesions
Early detection or prevention of procedural complications
Earn time during procedure

o Imaging techniques are for defining the anatomy

o Intracardiac echocardiography (ICE)
• Accurate to describing the anatomy

o Contrast enhanced cardiac magnetic
resonance (ce-CMR)
• Accurate to identify CC’s into the core scar
Ablation with ICE
o
o

Allow us to watch the ablation tip
Identification of anatomic structures
•
•
•

o

Coronary cuspids
Papillary Muscle
Akinetic and Scar zones

Allow us to identify early complications during the
procedure
Usefulness of new imaging techniques
Usefulness of new imaging techniques
Image ablation with ICE
Epicardial Ablation with ICE

Bala et al. Cir Arrhythm Electrophysiol. 2011
ICE mapping
o What we can´t do with ICE?
• Identification of conduccion channels in Scar
and Border zones
ce-CMR
o Predictive value for ventricular arrhythmia
• Inducibility
• Mortality

o Scar tissue characterization
• Quantification
• Heterogeneity
Non-invasive Assessment of Cardiac Fibrosis

• Ce-Cardiac Magnetic Resonance
• Prognostic value for arrhythmia inducibility and mortality
• Scar tissue characterization (quantification / heterogeneity)

Infarct Core

Border Zone
Normal myocardium
Quantitative/qualitative estimation of Cardiac Fibrosis
High SCD risk patients

Low SCD risk patients

LVEF 35%

LVEF 35%

LVEF 35%

LVEF 35%

Fernández-Armenta J, Berruezo A, et al. Europace 2012.
Image processing

Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
Scar-Anatomy and 3D Structure of
Conducting Channels
Anatomy and Scar Integration
Scar - Anatomy and 3D Structure of
Conducting Channels
Signal Intensity Maps
o Myocardial wall
thickness 10%
and 25%
• Border zone
channel is
suggested
• Sequential
activation of
electrograms

Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
Identification of Conduction channels
Endo and Epicardial maps
Signal Intensity maps (SI)
Limitations of ce-CMR
o Image aquisition
•
•
•
•

The partial volume effect
The presence of ventricular arrhytmias
Lack of adequate apneas
Variability of gadolinium kinetics

o Identification of channels in EAM is manual
•

CC branching with a trajectory hard to define

o This technique larger and prospective studies
cc-CMR guided ablation
Summary
• Continuous improvement in cardiac imaging for
arrhythmias in last years
– Diagnosis and risk stratification
– Guiding interventions
– Saving time and be more accurate

• Evolution from gross anatomy to histology and function
• Need for cooperation between cardiac imaging specialist
and electrophisiologist

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Usefulness of new imaging techniques

  • 1. Usefulness of new imaging techniques to identify complex arrhytmogenic substrates in the ventricle Venice Arrhythmias 2013 “SOLAECE Corner” Gerardo Rodríguez Diez MD National Medical Center “20 de Noviembre” ISSSTE. México D.F. SOLAECE Treasurer
  • 3. Key points o Background o Ablation targets o New imaging techniques • ICE • ce-CMR o Conclusion
  • 4. Background o Non structural heart disease (focal origin) • Increase Automaticity • Triggered activity (early or delayed afterdepolarizations) o Structural Heart disease (scar-related) • Ischemic or no Ischemic • Relative large reentry circuits • Complex substrates around the fibrosis scars or border zones
  • 5. Ventricular Arrhythmias and Scar • Critical anatomic substrates sustaining VA’s, shows different degrees of fibrosis / scar (even in cases of focal origin) *90% of sustained VT’s are due to reentry involving an area of ventricular scar. 10% remaining are due to reentry or automaticity involving the Purkinje system. Pogwizd SM, et al. Circulation 1998. *Stevenson WG, Heart Rhythm 2013.
  • 7. Targets for ablation o Conduction channels (CC’s) • • Bundles of viable myocardium inside scars that become part of reentrant circuit during VT Are located at any level of the myocardium wall with variable thickness and a 3D- structure
  • 8. VT ablation targets o Electroanatomic maps (EAM) • • Is a depiction of cardiac anatomy (through a color-coded display of the intracardiac electrogam) Areas of interest • reduce electrogram amplitude in voltage maps o Normal Electrogram amplitude • >1.5mV o Border zone electrogram • 0.5-1.5 mV o Core scar • < 0.5 mV
  • 9. Catheter Ablation of reentrant VT o Goal: Identification of critical isthmus of conduction that is part of the reentrant circuit
  • 10. Conventional VT ablation limitations o o o o o Hemodynamic intolerance Multiple changing morphologies Hemodynamic collapse Noninducible VT during EP testing Recurrences (50-88%) o Identification of the underlying substrate using voltage mapping with 3D reconstruction point by point • It’s cumbersome • Requires considerable skill • It’s time consuming
  • 11. Complex imaging techniques o Rationale • • • • Characterization of arrhythmogenic substrates Direct guidance and characterization of ablation lesions Early detection or prevention of procedural complications Earn time during procedure o Imaging techniques are for defining the anatomy o Intracardiac echocardiography (ICE) • Accurate to describing the anatomy o Contrast enhanced cardiac magnetic resonance (ce-CMR) • Accurate to identify CC’s into the core scar
  • 12. Ablation with ICE o o Allow us to watch the ablation tip Identification of anatomic structures • • • o Coronary cuspids Papillary Muscle Akinetic and Scar zones Allow us to identify early complications during the procedure
  • 16. Epicardial Ablation with ICE Bala et al. Cir Arrhythm Electrophysiol. 2011
  • 17. ICE mapping o What we can´t do with ICE? • Identification of conduccion channels in Scar and Border zones
  • 18. ce-CMR o Predictive value for ventricular arrhythmia • Inducibility • Mortality o Scar tissue characterization • Quantification • Heterogeneity
  • 19. Non-invasive Assessment of Cardiac Fibrosis • Ce-Cardiac Magnetic Resonance • Prognostic value for arrhythmia inducibility and mortality • Scar tissue characterization (quantification / heterogeneity) Infarct Core Border Zone Normal myocardium
  • 20. Quantitative/qualitative estimation of Cardiac Fibrosis High SCD risk patients Low SCD risk patients LVEF 35% LVEF 35% LVEF 35% LVEF 35% Fernández-Armenta J, Berruezo A, et al. Europace 2012.
  • 21. Image processing Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
  • 22. Scar-Anatomy and 3D Structure of Conducting Channels
  • 23. Anatomy and Scar Integration
  • 24. Scar - Anatomy and 3D Structure of Conducting Channels
  • 25. Signal Intensity Maps o Myocardial wall thickness 10% and 25% • Border zone channel is suggested • Sequential activation of electrograms Fernandez-Armenta, Berruezo A, et al. Circ Arrhythm Electrophysiol 2013
  • 29. Limitations of ce-CMR o Image aquisition • • • • The partial volume effect The presence of ventricular arrhytmias Lack of adequate apneas Variability of gadolinium kinetics o Identification of channels in EAM is manual • CC branching with a trajectory hard to define o This technique larger and prospective studies
  • 31. Summary • Continuous improvement in cardiac imaging for arrhythmias in last years – Diagnosis and risk stratification – Guiding interventions – Saving time and be more accurate • Evolution from gross anatomy to histology and function • Need for cooperation between cardiac imaging specialist and electrophisiologist

Notas del editor

  1. Añadir después de ésta los Kaplan del paper del Europace. Se ahorran DAIS.