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EP on EP Episode 74: PVC/NSVT Ablation in "Normal ...
PVC/NSVT Ablation in "Normal Hearts" w/ Pasquale S ...
PVC/NSVT Ablation in "Normal Hearts" w/ Pasquale Santangeli, MD, PhD (Part II)
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♪ ♪ Hi, this is Eric Prostowski and welcome to another episode of EP on EP. We're delighted to have Pasquale Santanginelli back again for part two of this wonderful discussion on VT ablation in patients with normal hearts. Welcome Pasquale. Thank you for having me, Eric. The papillary muscles. Can you just give us like your, your approach? I mean, they can be real tricky. I mean, I know stability is an issue and I know that it's not uncommon, especially in prolapse, to have multiple areas. How do you approach the PAPs? So I have to say those are probably the most challenging type of PVCs or VT that we have to really target. And the reason for that is because we are limited in terms of the anatomic reconstruction, even if you're using tracheo-echo is always a 2D modality. And we very rarely can appreciate all the crevices or the pouches around the PAP muscles. And also the sometimes that multiple heads becomes really complicated. The second aspect. So, yeah. So the first issue of course, mapping the entire, I would say width and length of the structure and the complexity of the structure. And the second issue is ablation, of course, because right now, and probably electroporation will overcome that issue because you don't need to be in contact. But right now, ablation is a contact sport. So we have to be in contact with the tissue that we want to ablate. And with a beating heart and the patient breathing as well, which is typically what we do with conscious sedation for idiopathic PVCs, it's extremely challenging to keep your catheter position in the intra-cavitary structure for long enough to create an adequate lesion. The second issue is that they're extremely arrhythmogenic and where sometimes you come on a radio frequency, patients go in polymorphic VT, or sometimes even VF. We've seen that we, and that of course, you can really keep ablating in those conditions. So there are some tricks that you can use, for example, cryoablation with a cryocatheter. Usually we use a six millimeters, but there is experience also with eight millimeter. Does help fairly well in those, in those situations, just because first of all, it's not arrhythmogenic. So cryo is different from radio frequencies. You won't see any poor arrhythmia from it. And second of all, it will stick to the papillary muscle throughout the lesion. And it's been very effective when radio frequency ablation has failed. And that- Oh, I'm sorry. Go ahead. I was going to say, it sounds like though, you'll try RF first, and that's kind of your bailout ablation. Cryo, it's not like you would use that initially. Yes, exactly. We use actually a radio frequency always, and cryo is only in a minority of patients. We reported a small series in your journal, in what used to be your journal, when you were the editor. You were the editor. You were the editor at the time. So- 15 years was just enough. But, but yeah. So, and we show that increases success in cases that were refractory with radio frequency ablation. And again, there was only as used as a bailout and we don't use it as a first line approach in these cases. So the papillary muscles can be thick and sometimes you're not exactly sure, right? Where things are coming from. I know that you can hit a site you think is good and then they exit somewhere else. So do you also use a strategy of lower power long time? Or what is your ablation strategy? For the papillary muscles? Yeah. So, yes, historically we've been using the same and the papillary muscle. I have to say, I personally have transitioned to higher power and just because typically the contact force that you can achieve and the contact system in the astral is not adequate. So I, it's very rare to have a steam pop on the papillary muscle just because, especially when you're ablating the body of the papillary muscle or the tip of the papillary muscle because you're not in contact throughout the cardiac cycle. So usually I use higher power because you can afford to have higher power. One of the issues that we didn't talk about the LV summit and also even more important for the pump muscle is whether we're hurting people with ablating these structures. When you ask about the power delivery, there are some case reports of pseudoaneurysm in the LV summit for patients that were treated with very high power for long duration. So always be careful that trade the power according to an impedance drop. In the papillary muscle region, one of the concerns is the mechanical injury to the papillary muscle and therefore much of regurgitation. That hasn't been shown at least in our center. We always use intracardiac echo to decide where to ablate. We monitor our lesions and we have actually an abstract, not mine, it was Dr. Dixit actually put it together for HRS that shows no impact of ablation the papillary muscle on the muscle about function over time. That's great to know. Of course, I don't ever stand the test of time. Someone is absolutely gonna get into trouble someday and they're gonna say, but I read this paper from Pasquale and he said, you don't get into trouble and he'll pay his check and he'll move on. But let me end with this. You get everything set, you've got your 12 lead, you figured out where you're gonna head, you get in the lab and you have no PVC and you do the usual running in from ISO to epi to whatever the medicine du jour is to try to make PVCs can happen. Just briefly tell us, what do you do? What's your approach at that point? Yeah, so my personal approach is to bring the patient back. And unfortunately, because I am not a strong believer of pace mapping. And the reason why I don't believe that in particular in the outflow tract, because there is a lot of data that shows preferential conduction in that area. So you can have early activation in the coronary cusp, you can have best pace map a centimeter away in the RVOT, et cetera. The criticism that my colleagues usually with my approach is that I don't look at the pace map carefully looking at all the notches, et cetera. So if you do it right, if you spend a lot of time, you may have some success. The reality is, I think we need to have more studies because there are some data from the 80s that PVCs come and go. And if a patient comes to the epi lab with no anesthesia and there is no PVCs, probably in that phase where the PVCs are going away, if you repeat a halter a month later and they're gone, is that because you did a population gathered by pace map or it just simply regression to the mean and there was just a good month for the patient? So I think we need to be very careful when we interpret this data, even our own successes guided by a strategy that doesn't show acute success. In other words, if a PVC is in front of you, you could turn on a raft and they go away, they vanish, you know that you did something. If the patient in the lab has nothing and you start pace mapping here and there and deliver a couple of lesions, a halter a month later and there is no PVCs, is that a success or not? I mean, statistically maybe, but I mean, there is a lot of chance that comes into play in my opinion. So I think you bring up an important point. I'll just make two quick comments and then you and I will finish up this great interview. You've been terrific, great information Pasquale. Number one, I've been routinely doing now a seven-day halter. They're simple, you put a patch on. Because before I send my patients to my ablators in the lab I wanna get a sense that really every day they're having something. Because if I get a patient that has 15,000 PVCs one day and then 2000 for three or four days in a row, I know that could be a struggle in the lab. And it's the kind of thing, maybe that's not the best patient at that point. The second thing is you're absolutely right with the PVCs going away. Many years ago, decades ago, there was a study published. I don't remember if it was myxilatine, but it was one of the drugs where they had a washout period and they stopped the drug for like a few days and repeated halter monitors. And all these patients, many of whom we thought the drug had suppressed all their PVCs, guess what, they were gone. And they were just gone. So we all know in the outflow track area, I can't say that's true for other areas, PVCs over time can go away. So your point is extremely well taken that we probably ought to have some better metrics for calling success. We shouldn't look at a halter a week later. I think your point's well taken. That would make a nice multi-center study like we're doing with AFib now, looking at the burden because they can be evanescent, right? And you think you've got a success or you think you made a success when they went away on their own. So I think you raised a good point. If I can just add one more thing. I mean, actually, one circumstance where PISMAP works is when we have a little bit of a patch of a substrate where you can target the long-stemmed TQ-RS and the PVCs are coming from around there, even in the outflow tract. And in that we did report good outcomes and Rob Schaller was actually the senior author of that paper. I just want to add that just to give the full picture, but in general, I don't particularly like to use PISMAP in. Well, that'll be a big controversy. When this is posted, I can see Twitter going now because there are camps with that and you're right, but your approach is obviously maybe a little safer, but I know I'll get beat up on that one. Pasquale, this has been a fabulous interview from soup to nuts on what you call normal to how do you ablate certain really gnarly areas to how you define success. Thank you so much for educating all of us in this area. Thank you for having me, Eric. It's been a pleasure. Thank you.
Video Summary
In this episode of EP on EP, Eric Prostowski interviews Pasquale Santanginelli about ventricular tachycardia (VT) ablation in patients with normal hearts. They discuss the challenges of targeting VT originating from the papillary muscles, including limited anatomical visualization and the need for contact during ablation. Santanginelli shares that cryoablation can be effective when radiofrequency ablation fails, as it is not arrhythmogenic and sticks to the papillary muscle. He also emphasizes the importance of careful power delivery to avoid complications and discusses the limitations of pace mapping in the outflow tract. They conclude by highlighting the need for better metrics to determine the success of ablation procedures for PVCs.
Keywords
Ventricular tachycardia
ablation
papillary muscles
cryoablation
power delivery
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