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Nanjing Medical University Affiliated Hospital Jiangsu Provence Hospital Fengxiang Zhang

Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping. Nanjing Medical University Affiliated Hospital Jiangsu Provence Hospital Fengxiang Zhang.

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Nanjing Medical University Affiliated Hospital Jiangsu Provence Hospital Fengxiang Zhang

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  1. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping Nanjing Medical University Affiliated Hospital Jiangsu Provence Hospital Fengxiang Zhang

  2. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Background • Non-contact mapping (NCM) was used for the right ventricular outflow tract (RVOT) ventricular tachycardia (VT) or premature ventricular contractions (PVC) mapping and ablation for many years • However, the long term recurrence rate was controversial

  3. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Inclusion criterion • Symptomatic idiopathic VT or VPCs with a LBBB morphology, an inferior axis, and the precordial lead transition zone ≥ V4 • RVOT VPCs burden ≥ 15% • Patients either failed or intolerant to beta-blockers and / or class Ⅲ or IC antiarrhythmic agents • They without structure heart disease and with normal LVEF

  4. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Exclusion criterion • The origin of VT/PVCs outside of RVOT • Structure heart disease • Polymorphic ventricular arrhythmias • Reversal RVOT VT/VPCs • Another organ disease • Younger than 18 years old • Pregnant

  5. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Patient characteristics • From May, 2006 to Dem, 2011, altogether 188 pats’ VT/PVCs morphology were LBBB underwent ablation • Pulmonary artery trunk origin in 20 pts • Left ventricular outflow tract origin in 10 pts • The CS system in 4 pts • A total of 154 patients were finally included for analyzing. Patients were enrolled into non-contat mapping (EnSite array) group (group A, n=136) or contact mapping (EnSite NavX or CARTO-XP), group (group B, n=18)

  6. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Methods: • Group A • The non-contact mapping was used to set up the geometry of RVOT, and identify the EA and BO sites of RVOT VT/PVCs • A broad color setting with high pass filter set at -0.1 mv and low pass filter set at -2 mv. EnSite highpass filter set at 4Hz • At the BO site, the color coded activation map showed the white color-zone shrink down to the red color-zone, where the local virtual unipolar ECG exhibited the maximum dV/dt • At the EA site the red color-zone further shrinks down to the blue color

  7. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Methods: • Group B • Activation mapping with the assistance of Ensite NavX or CARTO-XP was performed to indentify the earliest site of RVOT VT/PVCs • Two groups • Bipolar pace mapping was performed with ablation catheter tip at the EA and BO sites, respectively • Pacing was performed at twice the diastolic threshold with the pacing cycle length was equal to the couple interval of the PVCs, when mapping VT, the pacing cycle length was equal to the VT cycle length • Pacing score （24）was performed by four physicians who were blind to this study

  8. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping EA LAO 30° RAO 30° BO • Methods: Clinical PVC Pace mapping Activation mapping

  9. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Methods: RAO 30° Activation mapping Pace mapping LAO 45°

  10. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Methods: RAO 30° Pace mapping LAO 45° 28ms

  11. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Follow up • After the procedure, ECG monitoring was performed for 24 hours in all pts • All pats were seen in an outpatient clinic every month after the procedure in the first three months, and then followed up every 6 months • During each clinic visit, a 12-lead ECG was recorded in each patient and 24-hour Holter monitoring was performed at every follow-up

  12. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • Baseline characteristics

  13. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • EPS characteristics

  14. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • Acute ablation success and failure rate

  15. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • Ablation parameters

  16. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • X-ray time and dose

  17. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • The total procedure duration P=0.009 P=0.000 P=0.582

  18. P=0.000 P>0.05 Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • Recurrence of RVOT VT/PVCs Free from VT/PVC recurrence Follow-up (day)

  19. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • Recurrent time

  20. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • The second procedure • The second ablation was successful in one patient in each group. The other nine patients refused to undergo RF ablation again

  21. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Multivariate analyses showed that the independent predictors for VT/PVCs recurrence after ablation were stimulation current at the EA site (EA current) (P=0.042, HR 1.102, 95% CI 1.003-1.210) • The ROC analysis showed that EA current more than 18.01 (sensitivity 72.73%, specificity 67.42%, area under the ROC curve was 0.727) was able to predict the VT/PVCs recurrence • Results: • Predictor for VT/PVCs recurrence

  22. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Results: • Complication P>0.05

  23. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • NCM, as described, was high resolution simultaneous activation maps of the entire cardiac chamber from just one beat of VT. Noncontact endocardial mapping was first used for RVOT VA a mapping in 1987 • And then, the utility of the MEA had been reported for a series of cardiac arrhythmias • The main advantage of the NCM over other mapping is accurate and rapid mapping of a VT or PVC • Discussion: Circulation. 1987;75:272–281. J Am Coll Cardiol. 2004;44:1080–1086. Am J Cardiol. 2001;87:1017–1021. Heart Rhythm. 2007; 4(7): 959-63. Heart Rhythm. 2007;4:1497–1504.

  24. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • The acute success rate of RF ablation was 88%-100% in patients with RVOT VT/PVCs by using NCM was very encouraging • The success rate was 93%-96% in patients with RVOT VT/PVCs underwent mapping by using electroanatomic mapping • Discussion: JCE. 2001;12(5):511-7. JCE. 2003;14:602– 608. JICE. 2012.7. JICE. 2007;19 (3):187-94.

  25. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • The recurrence was 7% in this study • The long term recurrent rate varied 11.11%~22.22% in different studies • In the contact mapping group, the recurrence was 4%-32% • Discussion: Heart rhythm. 2010 Jun;7(6):731-9. J Am Coll Cardiol. 2002;39:1808–1812. Clin Cardial. 2010 Mar;33(3):E19-24.

  26. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Discussion: • In this study, the stimulator current more than 18 ma at the EA site was the independent predictor factor for RVOT VT/PVCs recurrence • Monophasic R-wave in lead I was the predicted the recurrence of RVOT VT/PVCs • One induced VT morphology, a delta wave-like beginning of the QRS, and a VT/pacemap correlation < 11 of 12 leads were the failed and recurrence factors for RVOT VT/PVCs in Rodriguez’s report. • QRS morphologic variation was the only statistically significant ECG factor to predict idiopathic RVOT VT or ectopy recurrence Europace. 2006; 8 (8): 601-6. Am J Cardiol 1997;79:309–14. J Electrocardiol 2003;36:327–32.

  27. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping RVOT VT/PVCs, n=156 Non-contact mapping, n=136 Contact mapping, n=18 Failed case, n=9(6.62%) Acute success case, n=127 (93.38%) Failed case, n=1, (5.56%) Acute success case, n=17 (94.44%) Long term recurrent case, n=9 (7.09%) Long term success case, n=119 (93.70%) Refused ablation, n=9 Long term success case, n=15 (88.24%) Recurrent case, n=2 (11.76%) Refused ablation Second successful ablation cases, n=1 Refused the second procedure case, n=1 Second successful ablation cases, n=1 Refused ablation, n=8

  28. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • This study was retrospective, not prospective and randomized • The sample was so small in group B, only 18 cases • The follow-up was so short in the group B, but it did not affect the analysis for advantage of NCM • Limitations:

  29. Long term success rate of ventricular arrhythmia originated from the RVOT underwent mapping and ablation by using non-contact mapping • Conclusion • NCM is a reliable and effective technique for the RVOT VT/PVCs mapping and ablation

  30. Thank You for Your Attention!

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