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RescueAblationofElectricalStormsinaPatientwith

RemoteMyocardialInfarctionKatherineFanGranthamHospitalHongKongSARPatientMr.LM/64HistoryofinferiorMI1989-MVRforpapillarymuscleruptureandsevereMRIschemiccardiomyopathy(EF30%)VT1997-ICDimplanted/generatorchange2002Chronicsmoker/COPDVentricularArrhythmiasICD(single-chamber)1997Amiodaroneaddedin2001forPAF/NSVTRecurrentVTepisodesin3/2005withincreaseddosageofamiodaroneDevelopedSOB-diagnosedamiodaroneinducedpulmonaryfibrosis:Amiodaronestopped/Highdosesteroidsrequired-blockers/sotalol-nottolerated–exacerbationofCOPDRecurrentVTepisodes-mexiletinestartedbutcomplicatedbyneurologicalsigns(limbtremorandgaitinstability)ElecticalStormsNov2005-admittedafterrecurrentICDshocksInterrogations:58episodesofVTdetectedMostterminatedwithATPSomeaccerleratedtofastVTwhichwasthentermiantedwithcardioversionshocksEarlyre-initiationofVTVTMorphologiesLBBB/LeftsuperioraxisQRSRBBB/RightsuperioraxisQRSATPRBBB/Rsup

LBBB/LsupRBBB/RsupMitralvalveprothesisRAOINFSinusRhythmVT1VT2LesionsCreatedTerminationofVT(RF#38!)onRFCatheterAblationoftheMitralIsthmusforVTassociatedwithInferiorInfarction

Wilberetal.Circulation1995;92:3481-3489Byvirtueofitsnarrowdimension,theisthmusbecamethevulnerablepointtointerruptthiscircumferentialactivationRBBB/RightsuperioraxisLBBB/LeftsuperioraxisMitralIsthmusVentricularTachycaridaCriticalzoneofslowconductionactivatedparalleltomitralisthmusineitherdirectionresultingin2distinctbutcharacteristicQRSconfigurationsLBBBwithleftsuperioraxis-rSinV1andaVR/RinV6,I,aVLRBBBwithrightsuperioraxis-RinV1andaVR/QSinV6,I,aVLLBBB/LADRBBB/RADWilberetal.Circulation1995DynamicSubstrateMap

SinusRhythmLowVoltageZone

RAOviewInferiorviewDynamicSubstrateMap

VentricularTachycardiaRAOviewInferiorviewLowVoltageZone

CompositeSubstrateProfileDSMSinusRhythmCompositeSubstrateMapDSMVTFixedBlockFunctionalBlock

MarkedLesionsRAOviewInferiorviewAnotherMarkedLesionsRAOviewInferiorviewSubstrate-OrientatedVTAblationAdefinitetriggerordelineatedscarhasbeencharacterizedasarequirementforsubstrateorientatedablationofintractableunmappableVTTargetsCriticalisthmusAreasofslowconductionExitsites-oftenlocatedattheborderofthescarredmyocardiumScarBorderZoneSubstrateVToriginatedfromareaofdiseasedtissuesurroundingdensescarBasedonsurgicalapproachestotreatVT(sub-endoardialresection),methodsofablatingischemicVTby“substratemapping〞inSRhavebeenusedsuccessfullyinptswithdrugrefractoryhemodynamicallyunstableMMVTUseelectroanatomicalvoltagemappingtodefineregionsofscarandviableendocardiuminSRfollowedbyablationsintheborderzoneregionsAnatomicalvsFunctionalSubstrate

LimitationofVoltageMappingduringSRBoundariesoftheisthmuscouldbefunctionallinesofblocknotdetectedduringSRDispersionofvoltage(heterogeneity)inscarareasmayappearonlywhenactivatedatVTrateand/ororientationPostMIstructuralremodelingAlterationofanisotropydependedonelectrotonicloadsandorientationSummarySuccessfulablationofmitralisthmusforVTassociatedwithremoteinferiorinfarctionCharacteristicofVTmorphologiesanditscorrespondingactivationmappingsdemonstratedDynamicsubstratemappingduringSRandVTprovidedcomplimentarydataonsubstrateidentification(anatomicalvsfunctional)VentricularTachycardia1VentricularTachycardia2RelationshipBetweenSuccessfulAblationSitesandtheScarBorderZoneDefinedbySubstrateMappingforVentricularTachycardiaPost-MI

Vermaetal.JCE2005:16:465-47129598157923*Densescar=bipolarvoltage<0.5mVSuccessfulAblationWithinScarCriticalisthmusmayoriginateinscarandexitinborderzoneormayexistentirelywithinscarThinstrandsofsurvivingmyocytes“zigzagging〞throughdenseareasofscar-substrateThicklayersofsurvivungmyocardiumexistingbeneathdenseendocardialscar-?returnpathofcircuitLinearablationsthatextendoutsideofthescarborderandintotheregionsofdenseinfarctionmayberequiredSomeadvocatedtargetingsiteswithinscarbyidentificationofisolated,delayedcomponentsoflocalEGMAnatomicalSubstratevsElectrophysiologicalSubstrateAnisotropy-determinedbycellorientation/morphologyandcell-to-cellconnections(gapjunctions)Diseasedstate(egMI/heartfailure)-structuralremodelingalterstheansiotropyandincreasesitsheterogeneityandpotentialforarrhythmiadevelopment?Extentof“functionalsubstrate〞dependsontheelectrotonicloadsandorientationEntrainmentmap

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