false
Catalog
EP on EP Episode 51 - Non-invasive Mapping & Ablat ...
EP on EP Episode 51
EP on EP Episode 51
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Hi, this is Eric Vrstavsky. Welcome to another session of EP on EP. With me today is a friend and really an investigator doing some wonderful things in our field, Dr. Phil Kukulich, who is the Associate Professor of Internal Medicine and Radiation Oncology at Washington University. Welcome to the show, Phil. Thank you very much, Eric. Appreciate it. What I'm most interested in hearing about is this exciting work you're doing with non-invasive mapping and ablation. Let's first start, if you would, take us ... Nothing is ever what it looks like in a New England Journal paper. There's always a backstory. Could you take us through what got you to the point of being able to do what you did for the therapy part? Sure. This started back in fellowship when I worked with Yoram Rudy. We were developing ECGI, electrocardiographic imaging. It was very clear to me that we could take the pictures and understand the physiology from outside the body, and yet we were still introducing catheters to try to deliver the therapy inside the body. I've been thinking about how to non-invasively alter the physiology for some time. I originally thought this was actually going to be ultrasound, high frequency ultrasound, but it turns out that that's a difficult energy to control from outside the body. It turns out a mutual friend had introduced me to my partner, Cliff Robinson. He's a radiation oncologist who has really helped pioneer the field moving forward for therapy non-invasively. Before you can get to actually doing the therapy, you had to do the mapping. That didn't occur in a day. I know you did some early basic work, but tell us a little bit about the clinical work and why, for example, because I thought the place to start with ... I thought it was going to be AFib, to be frank. You surprised me. You did it in VT. Was there a decision process you went through? Did you think maybe you might do it some ... I mean, why did you do VT? I had a couple reasons for that. There's a couple really important reasons for that. Number one, you tell me the mechanisms of atrial fibrillation? I can't. Right. Until we understand those mechanisms well, I don't think this is the right time or place to deliver a therapy that we don't fully understand yet. Right. In other words, you don't envision this right now as just a therapy to encircle the veins, for example. Could we? Yes. Should we? No, not yet. Okay. I think when we're studying a new energy source, we're really using the patients who have exhausted all of their typical standard treatments. The patients that we are getting for these types of things, for non-invasive ablation, have already cycled through medications. They've already cycled through multiple catheter ablations, and they continue to have a life-threatening bad heart rhythm, VT. For me, the risk-benefit works in that population, and so that's why we feel comfortable in the refractory VT space right now while we learn, while we develop. All of those imaging tools that we have are really becoming great to understand ventricular scar, so MRI giving us the three-dimensional scar architecture, PET telling us about the metabolism of the scar. You overlay ECGI telling us about the electrophysiology as the electricity interacts with the scar. Where does it exit from? Where does it re-enter? I think the time is right to use image-guided ablation, and now we can deliver that ablative therapy on it, basically. So let me go back to the image part for just a moment before you get back to the therapy. This just may be my misunderstanding of the technology, but I thought it was sort of an epicardial marker. How does it, teach me something, how does it find an area on the endocardium or mid-myocardium? There must be something that you're looking for. I understand your question. In particular, we're talking about ECGI, or we're using cardioinsight technologies now. So it reconstructs unipolar electrograms on the epicardium. So it's not a bipolar map, as if we were to put in an ablation catheter and map bipolar. We're mapping unipolar. So it's not specifically just an epicardial information. Unipolar gives us the depth. We can understand the full depth. We're learning this now, endocardial unipolar mapping to determine what's going on on the epicardium and mid-myocardium as well. So these are reconstructed unipolar electrograms. What we're doing with this is we're looking first for the exit site, lining up where the exit site is relative to the scar. But in that same beat, that same single beat, you can follow the way the electricity interacts with the scar. Where does it re-enter within the scar? So you get exit site, you get entry site back into the scar, and then you can start thinking about where the diastolic potential, the diastolic corridor would be within that scar. So when you finally decided to do these, they're all ischemics? No, about half of them are ischemic, half of them are non-ischemic. So the non-ischemics were some epicardial sites where you've dialed it? Yes, absolutely. So we took basically anybody who had failed therapies already, and a handful of patients who couldn't get standard therapies. So we may have ablated somebody endocardial, they've had a CABG, so it's difficult to get epicardial, they've had a failed epicardial axis. Instead of putting them through a surgical procedure to try to get a catheter epicardially, we've enrolled them in these sorts of trials. But it's really been a give us your poor, tired, huddled masses. Give us anybody who's failed the standard therapies, and then we can see if this works. We're learning whether this is a better therapy for ischemic versus non. The jury is still out, but I would say if you look across the breadth of the data from the New England Journal paper, from the circulation phase one, phase two trials, it works for both. It controls ventricular tachycardia for both of these. So let me ask you as far as going forward, I mean your paper was very impressive, and congratulations on the work you and your colleagues did. It sounds, you know, most of us we think, oh no, you had to go get radiation therapy, it's usually, well like your title is, you're radiation oncology, now you don't look like an oncologist, but that's one of your titles. So it's a bit scary in a sense, I mean I can imagine if a patient has no other choice, though that's a different discussion, but I'm looking beyond that, I'm looking because of your paper, that's always the first group, right Phil? But there must be a game plan in your mind where this could become therapy for somebody and not as a last ditch. I mean, in other words, do you think the approach therapeutically you're taking is okay to do with people who haven't failed everything else? I guess that's what I'm saying. Yeah, that's a great question. There is a game plan, and we want to be very methodical about this. In particular, because radiation can have lasting effects down the road, I think we have to be very cautious and careful moving forward. The risk benefit makes sense for people who have no other options at the end of their lives. If there is radiation damage that happens 20 years down the road and we're having this conversation with a 75 year old man who's in VT storm, he's happy to reach 95 and be dealing with that, right? Exactly. But the creep will be there, and until we fully understand those risks, we should be very methodical about that creep and be very careful about how we do this. So that's a long winded way to say, yes, there is a plan. We start with the sickest, we move upstream carefully looking for side effects, carefully looking for ways to do it better. So forgetting the therapy part, but the mapping part, do you think we're getting closer to the point where using that technology might be a good thing to do in VT, even if you wind up using a catheter to oblique the patient, or are we not there yet? No, I think so. I think the question is, is image guided ablation enough now in 2019? Yeah, I think that's what I'm saying. And there are groups that are moving this forward. I think the MRI, the CT continue to be great ways to understand scar architecture. Our ability to overlie simulations of EP studies on top of that scar, giving us an idea of where circuits are most likely to occur. I think this is really exciting work that we're doing right now in 2019. Now we overlay ECGI or cardio insight into this, and I think we really have a great understanding of the full metabolism, architecture of anatomy, and electrophysiology. So I think we're there in 2019, and I think the sky's the limit as we move forward. I'm very excited. From a guy who wore lead for so many years, I have a bad back. I think anything that's going to be better for the patient and the electrophysiologist is a win-win situation, and you're to be congratulated for pioneering this area. Thanks for joining the show. Thank you. I really appreciate this opportunity.
Video Summary
In a video interview, Dr. Phil Kukulich discusses his work in non-invasive mapping and ablation therapy. He explains that his interest in non-invasive alteration of physiological processes started during his fellowship, and he began researching how to achieve this. The current focus is on refractory ventricular tachycardia (VT), a life-threatening heart rhythm disorder. Dr. Kukulich and his team use advanced imaging tools such as MRI and PET to understand ventricular scar tissue and overlay this information with electrocardiographic imaging (ECGI). The goal is to develop image-guided ablation therapy to treat VT effectively and safely. While the therapy is still being refined, the results so far have been promising for both ischemic and non-ischemic VT. Dr. Kukulich emphasizes the importance of carefully considering the risks and benefits before using non-invasive therapies in patients who have not exhausted other treatment options. However, he believes that image-guided ablation is an exciting area with great potential for future advancements.
Keywords
non-invasive mapping
ablation therapy
ventricular tachycardia
image-guided ablation
future advancements
Heart Rhythm Society
1325 G Street NW, Suite 500
Washington, DC 20005
P: 202-464-3400 F: 202-464-3401
E: questions@heartrhythm365.org
© Heart Rhythm Society
Privacy Policy
|
Cookie Declaration
|
Linking Policy
|
Patient Education Disclaimer
|
State Nonprofit Disclosures
|
FAQ
×
Please select your language
1
English