Disclosure of Relationships Wide Complex Tachycardias Consulting - PDF document

9/29/16 Disclosure of Relationships Wide Complex Tachycardias Consulting Fees/Honoraria: St. Jude Medical, Biosense Webster, Inc., Boston Scientific Inc., Medtronic, Inc., Boehringer Ingelheim, Boston Edward P Gerstenfeld MD Scientific, Rhythm Diagnostic Solutions, Inc. Professor of Medicine University of California, San Francisco Research Grants : Medtronic, Inc., Biosense Webster, Inc., St. Jude Medical ., Rhythm Diagnostic Solutions, Inc. ECG History Ø 72 year old h/o HTN, PAF admitted to OH with “WCT” Ø Echo with normal LV function EF 60%, LVH Ø Cath with no significant CAD Ø Started on amio and told to “see your cardiologist” Ø Readmitted in WCT and transferred for evaluation 1

9/29/16 Baseline – Does This Help? Diagnosis? a) SVT with aberrancy b) Preexcited SVT c) VT Kindwall Criteria (LBBB) ECG VT vs. SVT > 30 ms V1 or V2 > 60 ms Kindwall et al. Am J Cardiol 1988;61:1279-83. 2

9/29/16 Diagnosis? VT Exit Site? a) RVOT free wall a) SVT with aberrancy b) RVOT septum b) Preexcited SVT c) Parahisian region c) VT d) LV Summit e) Mitral annulus RVOT PVC PS MS AS VT Exit? a) RVOT free wall b) RVOT septum c) Parahisian region d) LV Summit e) Mitral annulus 3

9/29/16 RV Inflow Tract ECG Ø Positive in lead 1, some positive force (w) in avL, notching in the inferior leads MRI Next Best Step a) Transition to oral amiodarone and observe b) Perform PET/CT c) Perform cardiac MRI d) Plan EPS/ablation 1. Asymmetric thickening of the left ventricular septal wall with a ratio to the lateral wall thickness of 2.75:1. This is consistent with asymmetric hypertrophic cardiomyopathy. 2. Small area of dense transmural delayed enhancement at the base of the interventricular septum in the region of the asymmetric septal wall thickening. 4

9/29/16 RV Activation Map What is the best next step? a) Ablate at earliest site with RF b) Ablate at earliest site with cryo c) Map LV septum His d) Map aortic root RV e) Terminate procedure and try flecainide PA What is the best next step? R Cusp Activation a) Ablate at earliest site with RF His b) Ablate at earliest site with cryo RV RAO c) Map LV septum d) Map aortic root e) Terminate procedure and try flecainide 22ms His RV LAO 5

9/29/16 RF to Right Cusp Term VT R Cusp Activation Summary Ø 72 yo with parahisian VT Ø MRI with basal mid septal DE, ? HCM Ø Earliest activation in RV diffusely above His region Ø Successfully ablated from R cusp using ICE and EAM guidance Ø No VT with triples during PES after RFA 6

9/29/16 ICD? Summary a) Yes – single chamber intravascular ICD Ø Septal VTs can have a relatively narrow QRS Ø Suspect parahisian PVC/VT with LBB/inferior b) Yes – subcutaneous ICD axis, lead I ++ and aVL flat/”w” c) No Ø R cusp often safer and more stable then right parahisian region Ø Consider cryoablation if His present 7