catheter ablation of ventricular tachycardia
TRANSCRIPT
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Catheter Ablation of Ventricular Tachycardia
Lin Yenn-Jiang MD. Chen Shih-Ann MD.April 15, 2012
Advanced EP training, St. Jude Medical, Taipei
Taiwan Heart Rhythm SocietyDivision of Cardiology, Taipei Veterans General Hospital
and National Yang-Ming University, Taipei, Taiwan
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Experience of VT EPS/ABLin Taipei VGH 2001-2011
61%61%
12%12%
9%9%
9%9%
4%4%
2%2%
1%1%
1%1%
OT VTFVT
ARVC
CAD
DCM
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P=0.007
Survival of VT Patients According to National Mortality Data Base of Taiwan (up to 2011)
CAD, DCMCAD, DCM
ARVCARVC
RV-VTRV-VT
Brugada,VFBrugada,VF
Fascicular VTFascicular VT
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Different types of VTDifferent types of VT
Focal TypeFocal Type Reentrant TypeReentrant Type
Pace mapping, Activation map, Unipolar electrogram morphology
Entrainment technique, substrate mapping, Electrogram characteristics
Mapping and ablation VT differ by underlying condition and tachycardia mechanism.
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Focal Ventricular Tachycardia
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ICD Lead
LV apex
Septum
RVOT
Lin YJ et al. HRS abstract 2010
Reentrant Ventricular Tachycardia
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How to Map VTTools
Surface ECG: origin, exitPace mappingEntrainment technique: during VT,3D activation and substrate mapping:
Stable VT: NavX, CartoUnstable VT: Ensite Array, substrate map during si
nus rhythm
Location: RV, LV, and EpicardiumECG, substrate map, activation map
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Outlines
Outflow tract VT. ARVC/D.LV Fascicular VT.Papillary muscle VT.CPVT, BBRVT.Substrate VT: CAD, DCM.
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Outflow Tract Ventricular Tachycardia (OT-VT)
VT arises from the right ventricular outflow tract (RVOT-VT, left ventricular outflow tract (LVOT-VT), aortic cusps (Cusp VT), and from the pulmonary artery (PA VT)
OT-VT tend to occur in the absence of structural heart disease and are focal in origin, the 12-lead ECG recorded during VT is a precise localizing tool.
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Clinical Features of RVOT-VT
RVOT VT constitutes 75% of all patients with outflow tract VT
RVOT VT is more common in females 30-50 years old.
Symptoms include palpitations, dizziness, atypical chest pain, and syncope.
Exercise testing reproduces the patient’s clinical VT 25 to 50% of the time.
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Mechanism of RVOT-VT
Most forms of RVOT VT are sensitive to adenosine
Most likely mechanism is catecholamine mediated DAD and triggered activity.
Mediated by the activation of cyclic AMP. Can be induced in the EP lab with isoprote
renol, aminophylline, atropine, and rapid burst pacing but rarely with programmed ventricular extrastimuli.
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RVOT VTRVOT VT
IIIIIIaVRaVLaVFV1V2V3V4V5V6
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1. Important overlapping nature of the outflow tract course!
2. RVOT and PA lie anterior and to the left of the LVOT and aorta.
Outflow Tract AnatomyOutflow Tract Anatomy
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RVOT VT: Pace mapping ECG morphology
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Pulmonary Artery VT
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David Callans JCE 2009
Cross over of RVOT & LVOT region
AP viewAP view Superior viewSuperior view
RR
RR
LL
LL
I: biphasic, V1 :WI: biphasic, V1 :W
I: positive V1 :RSI: positive V1 :RS
AntAnt
RightRight
LeftLeft
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How to D/D RVOT and VT with ASC in origin
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LVOT and Aortic Cuspid VT VT arising from the LVOT shares similar character
istics to the RVOT VT because of a common embryonic origin.
ECG: LBBB with inferior axis with small R-waves in V1 and early precordial transition (R/S 1 by V2 or V3) or RBBB morphology with inferior axis and S-wave in V6.
Aortic cusp VT accounts for up to 21% of idiopathic VT.
More commonly arises from the LCC, than the RCC and rarely arise from the NCC.
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Aortic Cusp VT Morphology
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Tabatabaei and Asirvatham. Circ EP 2009;2:316-326
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LVOT VT Morphology
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Mapping Tool for OT-VT
ECG morphology Could be non-inducible
Pace mappingCould be large area 2 cm2: different chamber, scar, or epicardium,
Activation mapMore accurate: remain unsuccess: more mapping sites, epicar
dium, different energy sources,
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Spontaneous PVC Pace Mapping
Taipei VGH 2010
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PVC Disappearance Just After RF
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12
A BVT PM 1 PM 2
Free wall
Septal wall
Anterior wall
RVOT
Difficulty in Pace Mapping in RVOT-T (1)
Taipei VGH 2010
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Schema of the Ventricular Arrhythmia Origin, BreakoSchema of the Ventricular Arrhythmia Origin, Breakout Site, and Preferential Conduction From the LCC to tut Site, and Preferential Conduction From the LCC to t
he RVOThe RVOT
T. Yamada, et al JACC, 2007, Vol. 50, No. 9: 884-91
Difficulty in Pace Mapping in RVOT-T (2)
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Voltage of SR Spectral Analysis Activation of VT
RVOT-T : 3D mapping
Scar in the free wall site
3.5 cm from PV
Successful site
0.000
0.002
0.004
0.006
0.008
0.010
0.012
0.014
0.016
0.018
0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300
Free wall
septum
Eg during SR
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Summery
Carefully ECG interpretation and EP study to Carefully ECG interpretation and EP study to
localize the optimum ablation site for VT.localize the optimum ablation site for VT.
Usually not life threatening, and could be treated Usually not life threatening, and could be treated
conservatively.conservatively.
3D mapping system can be helpful (activation 3D mapping system can be helpful (activation
map or substrate map), but correct chamber, far-map or substrate map), but correct chamber, far-
field sensing, preferential conduction need to be field sensing, preferential conduction need to be
consideredconsidered. .
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Outlines
Outflow tract VT. ARVC/D.LV Fascicular VT.Papillary muscle VT.CPVT, BBRVT.Substrate VT: CAD, DCM..
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Idiopathic RVOT-TIdiopathic RVOT-T
Right ventricular outflow tract tachycardia (RVORight ventricular outflow tract tachycardia (RVOT-T) represents up to 10% of all ventricular tachyT-T) represents up to 10% of all ventricular tachycardias (VTs), and is considered as a benign disecardias (VTs), and is considered as a benign disease.ase.
Symptoms:Symptoms: Ranging from none to palpitations, li Ranging from none to palpitations, lightheadedness, dyspnea, or syncope. ghtheadedness, dyspnea, or syncope.
Arrhythmias:Arrhythmias: Frequent isolated PVCs, bursts of n Frequent isolated PVCs, bursts of nonsustained VT, or sustained tachycardia often fonsustained VT, or sustained tachycardia often facilitated by catecholamines or exercise.acilitated by catecholamines or exercise.
Ablation:Ablation: Acute success rate of focal ablation of Acute success rate of focal ablation of RVOT-T is 65–97% with rare complications. RVOT-T is 65–97% with rare complications.
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Arrhythmogenic RV DysplasiaArrhythmogenic RV Dysplasia Cardiomyopathy begins in RV with poor contractile fCardiomyopathy begins in RV with poor contractile f
unction and dilatation, progresses to LV finally.unction and dilatation, progresses to LV finally.
Histology:Histology: RV muscle becomes replaced by adipose RV muscle becomes replaced by adipose and fibrous tissue.and fibrous tissue.
Arrhythmia:Arrhythmia: Re-entrant Type (scarring & late Potentia Re-entrant Type (scarring & late Potentials) with LBBB type ECG; ls) with LBBB type ECG;
ECG:ECG: Diffuse T wave inversion over precordial leads, Diffuse T wave inversion over precordial leads, and Epsilon Wave. and Epsilon Wave.
Ablation:Ablation: The effect of catheter ablation is temporizin The effect of catheter ablation is temporizing, 1/3 epicardium, mostly reentry. Implanted cardioveg, 1/3 epicardium, mostly reentry. Implanted cardioverter defibrillator (ICD) is the only reliable therapy for rter defibrillator (ICD) is the only reliable therapy for sudden cardiac death.sudden cardiac death.
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Task Force Criteria
TF (Definite +)TF (Definite +) if meet if meet 2 major 2 major or or 1 major 2 minor 1 major 2 minor criteriacriteria
McKenna et al. 1994, BMJ
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TF Criteria
Positive TF criteria is important to diagnose Positive TF criteria is important to diagnose
ARVC/D and is specific to detect the future VARVC/D and is specific to detect the future V
F/ICD implantation/ CV mortality F/ICD implantation/ CV mortality
Malignant ventricular arrhythmia and late recMalignant ventricular arrhythmia and late rec
urrences may occur in patients with mild or urrences may occur in patients with mild or
atypical form of arrhythmogenic RV cardiomatypical form of arrhythmogenic RV cardiom
yopathy.yopathy.
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ECG of End stage ARVCRVEF=10%, LVEF=15%
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RV-VT, ARVC/D
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Multiple VT morphology in ARVC/D
Sinus rhythm voltage map
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Peri-valvular VT in a Patient with ARVC/D
Europace 2005Europace 2005
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Electrophysiology
RVOT-TNot Fulfilling TF
(RVOT-VT)78.4%
Definite ARVC 21.6% P value
Catheter mapping
RV ERP (msec) 215 ± 22 238 ± 32 0.016
Inducible sustained VT 24% 59% 0.001
Requirement of isoproterenol infusion
53% 26% 0.016
Tachycardia cycle length (msec)
315 ± 67 277 ± 94 0.109
3D mapping
Scar in the RVOT (voltage <0.5 mV)
37% 57% 0.416
Scar in the RV body 47% 57% 0.697
Total RV conduction time (msec)
129 ± 46 222 ± 77 <0.001
Chen SA et al. 2011 HRS abstract
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Factors VT
recurrence (+)
VT recurrence
(-)
Odds ratioCI (95%)
Multivariate analysis
P value
TF criteria (1 major one minor, or 3 minors)
35% 13%7.5
0.95-590.055
Substrate Mapping RV body & free wall scar
46% 17%5.9
1.02-340.047
Distance to the pulmonary valve (cm)
29±19 19±101.1
1.01-1.170.047
Predictor of VT Recurrence After Ablation in TF (-) Patients
The presence of Scar / Foci in FREE WALL indicated future recurrence in TF (-) patients
Chen SA et al. 2010 HRS abstract
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P=0.511
All CauseAll CauseMortalityMortality
Malignant Malignant arrhythmiasarrhythmias
TF (+) , 7.4%
TF (-), 3.1%
P=0.019
TF (+): 36%:
TF (-) : 14%
Follow-Up Duration
Cumulative Incidence Cumulative Incidence
Follow-Up Duration
Long-Term Outcome(Mean follow-up time for more than 2 years)
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Kaplan-Meier analysis of survival free of rapid VT/VF event in ARVC patients
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Summery of ARVC/D
The most specific criteria to predict the outcome of ARThe most specific criteria to predict the outcome of AR
VC patients: VC patients: TF criteriaTF criteria. .
Detection of atypical and early form of ARVC from idiopDetection of atypical and early form of ARVC from idiop
athic RVOT-T: athic RVOT-T: Substrate mappingSubstrate mapping..
Substrate characteristics of ARVC: Diffuse LVZ and lonSubstrate characteristics of ARVC: Diffuse LVZ and lon
ger activation time, and abnormal substrate in the Epi-eger activation time, and abnormal substrate in the Epi-e
ndocardium; Tachycardia: both focal and reentrant.ndocardium; Tachycardia: both focal and reentrant.
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Outlines
Outflow tract VT. ARVC/D.LV Fascicular VT.Papillary muscle VT.CPVT.Substrate VT: CAD, DCM, Brugada S.
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LV fascicular VT
Most common left ventricular VTMost common left ventricular VT
Morphology: RBBB pattern (post. fascicular type: Morphology: RBBB pattern (post. fascicular type:
superior axis and LAD. incidence 90%; ant. fascicular superior axis and LAD. incidence 90%; ant. fascicular
type: inferior axis, and RAD; incidence 10%)type: inferior axis, and RAD; incidence 10%)
is a reentrant VT that originates from the Purkinje is a reentrant VT that originates from the Purkinje
network near the left ant or posterior fascicle without network near the left ant or posterior fascicle without
structural heart disease.structural heart disease.
This VT can be ablated by the diastolic potentials (P1 This VT can be ablated by the diastolic potentials (P1
or DP) or Purkinje potentials during VT.or DP) or Purkinje potentials during VT.
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Posterior Fascicular VT
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Diastolic potential & Purkinje potential
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LPF
P1P2 (LPF)
LVSexit
100 ms
P2
P1 P1: antegrade limbLVS: retrograde limbP2 (LPF): bystander
A
H
A B
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Posterior Fascicular VT
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Where to Target
P1 (DP) in the mid-septum of LV (28-130 ms before QRS). The earliest P1 is not required, usually targeting the lower 1/3 of the P1 to avoid AVB.
If P1 could not be identified, target the fused and earliest P2 (PP) near the exit site of the tachycardia.
Perfect QRS match during pace mapping may not be required.
Anatomic-guided linear ablation, longitudinal transect the limb of FVT.
Conventional catheter is enough
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Outlines
Outflow tract VT. ARVC/D.LV Fascicular VT.Papillary muscle VT.CPVT, BBRVT.Substrate VT: CAD, DCM.
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LV Papillary M VT (PM-VT)
Catecholamine sensitive VT, arising from anterior anCatecholamine sensitive VT, arising from anterior an
d posterior papillary muscle.d posterior papillary muscle.
Relative benign course in the follow-upRelative benign course in the follow-up
Focal and non-reentrant in mechanism. Mostly preseFocal and non-reentrant in mechanism. Mostly prese
nted with burst VPCs, Extra-stimulation induced VT nted with burst VPCs, Extra-stimulation induced VT
(-), entrainment (-).(-), entrainment (-).
Require advanced imaging to locate the PM-VT (angioRequire advanced imaging to locate the PM-VT (angio
graphy, TEE, ICE…)graphy, TEE, ICE…)
Could required Could required multiple site ablationmultiple site ablation and and irrigated RFirrigated RF
to achieve long-term success.to achieve long-term success.
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Location of Ant. and post. PAP M
JCE, Vol. 20, pp. 866-872, August 2009
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Surface ECG
NegativeNegative
Wide QRSWide QRS
Early transitionEarly transition
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VPC SR
Intracardiac recording
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ECG of Post. PAP VT
Circ Arrhythmia Electrophysiol. 2008;1:23-29
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Heart Rhythm, Vol 5, No 11, November 2008
Differentiation of PM-VT and Fascicular VT
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Outlines
Outflow tract VT. ARVC/D.LV Fascicular VT.Papillary muscle VT.CPVT, BBRVT.Substrate VT: CAD, DCM.
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Baseline EP characteristics: BBRVT
• BBRVT: Old patients , structure heart disease
• RBBB or LBBB,• Reentry: PPI<30 at RVap
ex, Critical delay of His-Purkinje system
• HV longer than SR, • HV during SR not normal
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CPVTCPVT
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Bidirectional VT, CPVTBidirectional VT, CPVT 3. Activation Mapping, during tachycardia
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ECG after ablationECG after ablation
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Outlines
Outflow tract VT. ARVC/D.LV Fascicular VT.Papillary muscle VT.CPVT, BBRVT.Substrate VT: CAD, DCM.
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Substrate VT
Localization of chamber (RV, LV, or Epi)
Localization of the disease susbtrate..
Identify the circuits of VT/VF, potential exit/entrance sites for VT/VF, by activation/entrainment during VT/VF and substrate during SR.
Determination of the targets for ablation.
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Strategy for SubstrateVT/VF ablation
Mappable/ inducible VT: Identification of the circuits and use of entrainment technique.
Unstable VT: substrate mapping during SR, use device, AAD to slow the VT rate.
Non-inducible VT: substrate mapping, pace mapping, consider autonomically or ischemically/mediated VT
Ineffective ablation: energy source, extensive ablation, or epi/intramural in origin.
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1. Localization of VT by ECG
Bundle branch morphology: RBB: LV, LBB: RV or LV septum.
Superior and inferior axis: sup. and inferior LV
Precordial transition: dominant R: mitral to basal, dominant S: anterior apex in location.
Positive concordance: Mitral annulus, negative concordance: LV apex.
Slurred wave, wider QRS, Q wave of lateral leads for LV-VT, R wave in RV-VT: Epicardial in position.
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2. Entrainment technique
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3. Electrogram Characteristics
Bipolar Eg: < 3 deflection, > 2 mV, < 70 msec, amplitude/duration<0.05
AbnormalAbnormal NormalNormal
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4. Substrate Mapping: Strategy
Zipes DP et al. Catheter Ablation of Arrhythmias, 2nd edition, 2002
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Ventricular Tachycardia RV ICD Lead Pacing Case 1
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LVZ
Ablation site
LVZ
LVZ
Bi-Ventricular Voltage Map
Lin YJ et al. HRS abstract 2009
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ICD Lead
LV apex
Septum
RVOT
Ischemic LV VT---Case 1The important to identify chamber to ablate
Lin YJ et al. HRS abstract 2009
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Lin YJ et al. HRS abstract 2009
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Ischemic LV VT---Case 2The important to identify the LVZ and critical
Channels and exit site
Tsai and Chen, Circ J, 2011
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Conclusions Outflow tract VT Outflow tract VT is the commonest form of idiopathic is the commonest form of idiopathic
VT. VT. ECG morphology ECG morphology is important for localization of focais important for localization of foca
l VT and exit site of substrate VT.l VT and exit site of substrate VT. Pacing mapping Pacing mapping may not sensitive to locate the sites may not sensitive to locate the sites
of foci in certain patients with focal VT, scar-VT, epicof foci in certain patients with focal VT, scar-VT, epicardial VT, and fascicular VT.ardial VT, and fascicular VT.
In the stable VT of abnormal ventricular substrateIn the stable VT of abnormal ventricular substrate: a: activation maps and entrainment technique are imporctivation maps and entrainment technique are important to decide the targets.tant to decide the targets.
In unstable VT, VF, and non-inducible VTIn unstable VT, VF, and non-inducible VT, substrate , substrate mapping during SR could be identify to determine thmapping during SR could be identify to determine the critical substrate. e critical substrate.
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Brugada syndrome---Case 3Identification of LVZ and prolonged potentials
Bipolar Eg > 1.5mVBipolar Eg > 1.5mV
Unipolar Eg > 5mVUnipolar Eg > 5mV
AbnormalAbnormal
RV endocardiumRV endocardium
RV endocardiumRV endocardium
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Brugada syndrome---Case 3Late potential maps
RV endocardiumRV endocardium RV epiardiumRV epiardium
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Post ablation> No inducible VT/VFPost ablation> No inducible VT/VF
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Before epicardial puncture After epicardial puncture
Changes in ECG during the procedureChanges in ECG during the procedure