ep laboratories in korea 1610 patients in 1998 rf ablation1,034 cases ep study576 cases seoul 9...
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EP LaboratoriesEP Laboratoriesin Koreain Korea
1610 patients in 19981610 patients in 1998
RF ablationRF ablation 1,034 1,034 casescases
EP studyEP study 576 cases576 cases
Seoul 9Seoul 9수원 1
인천 1
대전 1대구 3
부산 4
마산 1
광주 1
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ArrhythmiasArrhythmias
Early beatsEarly beatsUnexpected pausesUnexpected pausesTachycardiasTachycardiasBradycardiasBradycardiasBigeminal rhythmsBigeminal rhythmsGroup beatingGroup beatingTotal irregularityTotal irregularityRegular non-sinus rhythms at normal ratesRegular non-sinus rhythms at normal rates
By HJL MarriotBy HJL Marriot
Patients’ symptomsPatients’ symptomsPatients’ survivalPatients’ survival
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Enemies...Enemies...
BradyarrhythmiaBradyarrhythmia TachyarrhythmiaTachyarrhythmiaPausePause SupraventricularSupraventricularBlockBlock VentricularVentricular
Sudden Cardiac DeathSudden Cardiac Death Syncope Syncope of Unknown Originof Unknown Origin
Afghanistan_2002Afghanistan_2002
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EPSEPSA crystal ball to see what lies ahead?A crystal ball to see what lies ahead?
Local electrogramsLocal electrograms
Ability to recordAbility to recordAbility to reflect the electrical state Ability to reflect the electrical state
Programmed stimulationProgrammed stimulation
Ability to induce and terminateAbility to induce and terminateReentry > Reentry > Triggered activity > Triggered activity > Increased automaticityIncreased automaticity
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Anti-arrh
ythmic drugs
Anti-arrh
ythmic drugs
Device: pacemaker
Device: pacemaker
Device: defib
rillator
Device: defib
rillator
Ablation: c
atheter-based
Ablation: c
atheter-based
Ablation: s
urgery
Ablation: s
urgery
Tre
atm
ent
Tre
atm
ent
ArrhythmiasArrhythmiasEarly beatsEarly beats
Unexpected pausesUnexpected pauses
TachycardiasTachycardias
BradycardiasBradycardias
Bigeminal rhythmsBigeminal rhythms
Group beatingGroup beating
Total irregularityTotal irregularity
Regular non-sinus Regular non-sinus rhythms at normal ratesrhythms at normal rates
Treatment of ArrhythmiasTreatment of Arrhythmias
Patient’s symptomsPatient’s symptomsRisk associated with arrhythmiasRisk associated with arrhythmias
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Goal of EP StudyGoal of EP Study
1.1. Diagnosis of ArrhythmiaDiagnosis of Arrhythmia
2.2. Treatment of ArrhythmiaTreatment of Arrhythmia
3.3. Evaluation of TreatmentEvaluation of Treatment
4.4. Estimation of Risk-PrognosisEstimation of Risk-Prognosis
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Facts, Facts, SolvedSolved
Bradycardia Bradycardia without reversible causeswithout reversible causeswith symptomswith symptoms
PacemakerPacemaker
EPSEPSTo confirm the causal relationshipTo confirm the causal relationship
between patients’ symptoms andbetween patients’ symptoms and
observed bradyarrhythmiaobserved bradyarrhythmia
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77/77/F Recurrent syncopeF Recurrent syncope
54/54/M Dizziness and effort intoleranceM Dizziness and effort intolerance
62/62/M SyncopeM Syncope
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2 sec after RF: AP conduction block2 sec after RF: AP conduction block
RAO 30RAO 30oo
Map/RFMap/RF
CSCS
HRAHRA
RVARVA
HisHis
EP study ForEP study For
Catheter ablationCatheter ablation
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Facts, Facts, SolvedSolved
0
20
40
60
80
100
AVJ AVNRT AP VT AFL AT IST
SuccessComplication
NASPE 1998 NASPE 1998 Prospective Catheter Ablation RegistryProspective Catheter Ablation Registry3,357 patients(3,423 sessions)3,357 patients(3,423 sessions)Complication 2.59%Complication 2.59%No procedure-related deathNo procedure-related death
Scheinman MM, Huang S. PACE. 2000;23:1020-1028.Scheinman MM, Huang S. PACE. 2000;23:1020-1028.
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Solved with Catheter AblationSolved with Catheter AblationEP study for treatmentEP study for treatment
Structural HDStructural HD PrognosisPrognosis TreatmentTreatment
AtrialAtrial
APCAPC GoodGoodAtrial tachycardiaAtrial tachycardia
NonsustainedNonsustained GoodGoodSustainedSustained (+)/AT-related(+)/AT-related VariableVariable D, D, CurableCurable
PSVTPSVT GoodGoodCurableCurableWPW with afibWPW with afib Can be lethalCan be lethalCurableCurable
Atrial flutterAtrial flutter (+)(+) VariableVariable D, D, CurableCurable
Atrial fibrillationAtrial fibrillation (+)/(-)(+)/(-) LethalLethal
VentricularVentricular
VPCVPC Ventricular tachycardiaVentricular tachycardia (-)(-) GoodGood D, D,
CurableCurableNonsustainedNonsustained (+)(+) PoorPoorSustainedSustained (+)(+) PoorPoor
Ventricular fibrillationVentricular fibrillation LethalLethalARVD, Brugada, Long QTARVD, Brugada, Long QT LethalLethal
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Ventricular tachyarrhythmias Ventricular tachyarrhythmias with significant risk of deathwith significant risk of death
Aborted sudden cardiac deathAborted sudden cardiac death
Syncope of unknown originSyncope of unknown origin
Mortality-determining FactorsMortality-determining FactorsWeaponsWeapons Drug Drug
Catheter-based ablationCatheter-based ablationICDICD
Facts, Facts, Should be solvedShould be solved
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Facts, Facts, Should be solvedShould be solved
VTVT Myocardial InfarctionMyocardial InfarctionLV dysfunction or NotLV dysfunction or Not
CardiomyopathyCardiomyopathyDilated, HypertrophicDilated, Hypertrophic
PMVT/VFPMVT/VF ChannelopathyChannelopathyBrugada, Long QTBrugada, Long QT
Aborted SCDAborted SCDSyncopeSyncope
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High inducibility and reproducibility High inducibility and reproducibility in monomorphic VTin monomorphic VT
EP-guided drug treatmentEP-guided drug treatment
Ventricular Arrhythmias with MIVentricular Arrhythmias with MI
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Incidence of Sudden Death in Incidence of Sudden Death in Stratified Patients with Non-sustained VTStratified Patients with Non-sustained VT
Wilber DJ. Circulation. 1990;82:350-358.Wilber DJ. Circulation. 1990;82:350-358.
Noninducible (N = 57, SD/CA = 2)Noninducible (N = 57, SD/CA = 2)Inducible/SuppressedInducible/Suppressed(N = 20, SD/CA = 1)(N = 20, SD/CA = 1)
Inducible/Not SuppressedInducible/Not Suppressed(N = 20, SD/CA = 7)(N = 20, SD/CA = 7)
P < 0.001P < 0.0011010
2020
3030
4040
5050
6060
7070
8080
9090
100100
44 88 1212 1616 2020 2424Follow-up (months)Follow-up (months)
Su
rviv
al (
%)
Su
rviv
al (
%)
Facts, Facts, we’ve learnedwe’ve learned
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How to evaluate and predict the efficacy of treatment?How to evaluate and predict the efficacy of treatment?
Guided TherapyGuided Therapy
Spontaneous(sustained or repetitive)Spontaneous(sustained or repetitive)Spontaneous(sustained or repetitive)Spontaneous(sustained or repetitive)
Chronic atrial fibrillation, Repetitive MVT, Frequent PVCsChronic atrial fibrillation, Repetitive MVT, Frequent PVCs
Anti-arrhythmic treatment(drugs or ablation, etc)Anti-arrhythmic treatment(drugs or ablation, etc)
Termination or suppression of arrhythmiaTermination or suppression of arrhythmia
SporadicSporadicSporadicSporadic
NoninvasiveNoninvasive Prolonged monitoring to evaluate arrhythmia behaviorProlonged monitoring to evaluate arrhythmia behavior
InductionInduction Noninvasive challenge with TMT, isoproterenolNoninvasive challenge with TMT, isoproterenol Invasive challenge withInvasive challenge with programmed electrical stimulation programmed electrical stimulation
Anti-arrhythmic treatment(drugs or ablation, etc)Anti-arrhythmic treatment(drugs or ablation, etc)
Reapplication of evaluating methodsReapplication of evaluating methods
No inducible arrhythmia or significantly modifiedNo inducible arrhythmia or significantly modified
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95% 95% of Inducibility in Monomorphic VTof Inducibility in Monomorphic VTEP-guided drug treatmentEP-guided drug treatmentLimitation of drug treatment, especially Limitation of drug treatment, especially
in patients’ with risk in patients’ with risk
Ventricular Arrhythmias with MIVentricular Arrhythmias with MI
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CAST TrialCAST TrialCardiac Arrhythmia Suppression TrialCardiac Arrhythmia Suppression Trial
80
85
90
95
100
0 91 182 273 364 455
Days After Randomization
Pat
ien
ts W
ith
ou
t E
ven
t (%
)
Placebo (n = 743)
Encainide or Flecainide (n = 755)
P = 0.001
CAST investigators, NEJM 1989;321:406-412
Facts, Facts, we’ve learnedwe’ve learned
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95% 95% of Inducibility in Monomorphic VTof Inducibility in Monomorphic VTEP-guided drug treatmentEP-guided drug treatmentLimitation of drug treatment, especially Limitation of drug treatment, especially
in patients’ with risk in patients’ with risk No superiority of EP-guided treatmentNo superiority of EP-guided treatment
Ventricular Arrhythmias with MIVentricular Arrhythmias with MI
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ESVEMESVEM
VT, Cardiac Arrest, SyncopeVT, Cardiac Arrest, Syncope
Randomize
EPS Holter Monitor
ESVEM Investigators. Circulation. 1989;79(6):1354-1360.
Follow-Up
> 10 PVCs/Hour on Holterand Inducible at EPS
Drug 1
Drug N
ETT
Drug 1
Drug N
ETT
Facts, Facts, we’ve learnedwe’ve learned
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CASCADE Trial:CASCADE Trial:Cardiac Arrest in Seattle Conventional vs. Amiodarone Drug EvaluationCardiac Arrest in Seattle Conventional vs. Amiodarone Drug Evaluation
Out-of-Hospital VF ArrestOut-of-Hospital VF ArrestNot Associated with Q-wave MINot Associated with Q-wave MI
Randomization
Empiric Amiodarone
EPS or Holter-Guided“Conventional” Antiarrhythmic
Endpoints: Cardiac Arrest from VFCardiac MortalitySyncope Followed by ICD Shock
Facts, Facts, we’ve learnedwe’ve learned
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Total Cardiac SurvivalTotal Cardiac Survival
CASCADE Investigators. Am J Cardiol. 1993;72:280-287.CASCADE Investigators. Am J Cardiol. 1993;72:280-287.
Sudden Death Survival
CASCADE SurvivalCASCADE Survival
100%
75%
50%
25%
0%0 1 2 3 4 5 6 7
Years
P = .007 by Log Rank StatisticP = .007 by Log Rank Statistic
Amiodarone(113)Amiodarone(113)
Conventional(115)Conventional(115)
0 1 2 3 4 5 6 7Years
P < .001 by Log Rank StatisticP < .001 by Log Rank Statistic
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95% 95% of Inducibility in Monomorphic VTof Inducibility in Monomorphic VTEP-guided drug treatmentEP-guided drug treatmentLimitation of drug treatment, especially Limitation of drug treatment, especially
in patients’ with risk in patients’ with risk No superiority of EP-guided treatmentNo superiority of EP-guided treatmentSuperiority of ICD treatment, especially Superiority of ICD treatment, especially
in patients’ with riskin patients’ with risk
Ventricular Arrhythmias with MIVentricular Arrhythmias with MI
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ICD for prevention of deathICD for prevention of deathSecondary: AVID, CASH, CIDISSecondary: AVID, CASH, CIDISPrimary:MADIT, CABG-PATCH,SCD-HeFTPrimary:MADIT, CABG-PATCH,SCD-HeFT
Facts, Facts, we’ve learnedwe’ve learned
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AVID TrialAVID Trial(Antiarrhythmics Versus Implantable Defibrillators)(Antiarrhythmics Versus Implantable Defibrillators)
Patients with near-fatal ventricular Patients with near-fatal ventricular arrhythmiasarrhythmias
EmpiricEmpiric amiodarone, sotalolamiodarone, sotalol or or guidedguided sotalol sotalolversusversusImplantable defibrillatorsImplantable defibrillators
1016 patients1016 patientsSignificant mortality reduction Significant mortality reduction in ICD groupin ICD group
39±20%39±20% 27±21%27±21% 31±21%31±21%
Facts, Facts, we’ve learnedwe’ve learned
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Facts, Facts, we’ve learnedwe’ve learned
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MADIT MADIT (Multicenter Automatic Defibrillator Implantation Trial)(Multicenter Automatic Defibrillator Implantation Trial)
Inclusion CriteriaInclusion Criteria Prior Q-wave MIPrior Q-wave MIUnsustained VTUnsustained VTEF EF 35% 35%Inducible, non-suppressible VTInducible, non-suppressible VTNYHA Class I – IIINYHA Class I – IIIAge 25 - 80Age 25 - 80> 3 weeks from last MI> 3 weeks from last MINo requirement for revascularizationNo requirement for revascularization
Exclusion CriteriaExclusion Criteria Hx of VF or syncopal VTHx of VF or syncopal VTSymptomatic hypotension in stable rhythmSymptomatic hypotension in stable rhythmMI within last 3 weeksMI within last 3 weeksRecent PTCA or CABG (Recent PTCA or CABG (2 - 3 months)2 - 3 months)Advanced cerebrovascular diseaseAdvanced cerebrovascular diseaseAny non-cardiac disease associated with Any non-cardiac disease associated with
reduced likelihood of survivalreduced likelihood of survival
Moss AJ. New Engl J Med. 1996;335:1933-1940.
Facts, Facts, we’ve learnedwe’ve learned
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MADIT Patient FlowMADIT Patient Flow
Non-inducibleNon-inducible(n = 139)(n = 139)
Patients meetingPatients meetinginclusion criteriainclusion criteria
(N = 483)(N = 483)
EP studyEP study
SuppressibleSuppressiblewith IV with IV
procainamideprocainamide(n = 91)(n = 91)
Refused studyRefused study(n = 57)(n = 57)
InducibleInducible(n = 344)(n = 344)
Non-suppressibleNon-suppressible(n = 253)(n = 253)
Signed consent form, Signed consent form, randomizedrandomized
(n = 196)(n = 196)MADIT FDA Info Pack. May 16, 1996.MADIT FDA Info Pack. May 16, 1996.
Facts, Facts, we’ve learnedwe’ve learned
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MADIT SurvivalMADIT Survival
Moss AJ. New Engl J Med. 1996;335:1933-1940.
YearYear
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
0.00.000 11 22 33 44 55
Pro
bab
ility
of
Su
rviv
alP
rob
abili
ty o
f S
urv
ival
ConventionalConventionaltherapytherapy
DefibrillatorDefibrillator
No. of patients
DefibrillatorDefibrillator 9595 8080 5353 3131 1717 33
ConventionalConventional 101101 6767 4848 2929 1717 00therapytherapy
Facts, Facts, we’ve learnedwe’ve learned
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MADIT Antiarrhythmic Therapy UseMADIT Antiarrhythmic Therapy UseMedicationMedication
Antiarrhythmic medicationAntiarrhythmic medicationAmiodaroneAmiodarone 7474 22 4545
77Beta-blockersBeta-blockers 88 2626 55
2727Class I antiarrhythmic agentsClass I antiarrhythmic agents 1010 1212 1111
1111SotalolSotalol 77 11 99
44Beta-blockers or sotalolBeta-blockers or sotalol 1515 2727 1414
3131No antiarrhythmic medicationNo antiarrhythmic medication 88 5656 2323
4444
Other cardiac medicationOther cardiac medicationAngiotensin-converting-Angiotensin-converting- 5555 6060 5151
5757 enzyme inhibitors enzyme inhibitorsDigitalisDigitalis 3838 5858 3030
5757DiureticsDiuretics 5252 5353 4747
5252
Moss AJ. New Engl J Med. 1996;335:1933-1940.Moss AJ. New Engl J Med. 1996;335:1933-1940.
One MonthOne Month Last ContactLast Contact
ConventionalConventionalTherapyTherapy(N = 93)(N = 93)
DefibrillatorDefibrillator
(N = 93)(N = 93)
ConventionalConventionalTherapyTherapy(N = 82)(N = 82)
DefibrillatorDefibrillator
(N = 86)(N = 86)
Facts, Facts, we’ve learnedwe’ve learned
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EP study and CardiomyopathyEP study and Cardiomyopathy
Dilated CMPDilated CMPLow inducibilityLow inducibilityPoor correlation with clinical efficacy of Poor correlation with clinical efficacy of guided-treatmentguided-treatmentLimitation of drug selectionLimitation of drug selection
Hypertrophic CMPHypertrophic CMPPatients with syncope, VT, VFPatients with syncope, VT, VFHigh chance of inductionHigh chance of induction
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VT with MIVT with MIStable without LV dysfxStable without LV dysfx EP-guided drug TxEP-guided drug Tx
Catheter ablationCatheter ablationUnstable* without LV dysfxUnstable* without LV dysfx ICDICD
EP-guided drug TxEP-guided drug TxStable with LV dysfxStable with LV dysfx ICD, Catheter ablationICD, Catheter ablation
Amiodarone, sotalolAmiodarone, sotalolUnstable* with LV dysfxUnstable* with LV dysfx ICDICD
NSVT with MINSVT with MIWithout LV dysfxWithout LV dysfxWith LV dysfxWith LV dysfx EP studyEP study
VT with CMPVT with CMPStableStable AmiodaroneAmiodaroneUnstableUnstable ICDICD
AmiodaroneAmiodarone
Facts, Facts, justifiedjustified
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MADIT Patient FlowMADIT Patient Flow
Non-inducibleNon-inducible(n = 139)(n = 139)
Patients meetingPatients meetinginclusion criteriainclusion criteria
(N = 483)(N = 483)
EP studyEP study
SuppressibleSuppressiblewith IV with IV
procainamideprocainamide(n = 91)(n = 91)
Refused studyRefused study(n = 57)(n = 57)
InducibleInducible(n = 344)(n = 344)
Non-suppressibleNon-suppressible(n = 253)(n = 253)
Signed consent form, Signed consent form, randomizedrandomized
(n = 196)(n = 196)MADIT FDA Info Pack. May 16, 1996.MADIT FDA Info Pack. May 16, 1996.
Facts, Facts, we want to knowwe want to know
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MADIT IIMADIT II
No ICDNo ICD
Patients with LV dysfuction (LVEF Patients with LV dysfuction (LVEF 30%)30%)Regardless of the occurrence of NSVT Regardless of the occurrence of NSVT
RandomizationRandomization
ICDICD
Device-based EPSDevice-based EPS To know the effect of ICD To know the effect of ICD in the non-inducible patients in the non-inducible patients
Facts, Facts, we want to knowwe want to know
SCD-HeftSCD-HeftPatients with LV dysfuction (LVEF Patients with LV dysfuction (LVEF 35%)35%)CAD+DCMP, NYHA II+IIICAD+DCMP, NYHA II+III
RandomizationRandomizationICDICD
Conventional Rx + PlaceboConventional Rx + Placebo
Conventional Rx + AmiodaroneConventional Rx + Amiodarone
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Syncope of Unknown OriginSyncope of Unknown Origin
Head-up tilt table test, Head-up tilt table test, esp. esp. in structurally normal heart patientsin structurally normal heart patients
Predictive factors for positive EP studyPredictive factors for positive EP study
LV dysfunctionLV dysfunctionPresence of bundle branch blockPresence of bundle branch blockCoronary arterial diseaseCoronary arterial diseaseMyocardial infarctionMyocardial infarctionUse of class I antiarrhythmic drugsUse of class I antiarrhythmic drugs
Krol RB, Morady F, et al. JACC 10(2):358-63.
Facts, Facts, we’ve learnedwe’ve learned
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Diagnostic Yield in Unexplained SyncopeDiagnostic Yield in Unexplained Syncope
86 86 patients withpatients withunexplained syncopeunexplained syncope
Sra JS. Ann Intern Med. 1991;114:1013-1019.
29 patients(34%)
57 patients
tilt table test
Abnormal result Normal result
EP study
34 patients(40%)
23 patientsstill with
unexplained syncope(26%)
Syncope elicited
Normal response
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Findings and Treatment of Syncope Findings and Treatment of Syncope Patients with Abnormal EP StudyPatients with Abnormal EP Study
Findings in EP-positive patients (N = 29)Findings in EP-positive patients (N = 29)
SVT (n = 5)VT (n = 21) Sinus node dysfunctionor conduction disease(n = 3)
Permanent pacemaker (n = 3)
Antiarrhythmicsonly (n = 3)
Ablation (n = 2)
ICD (n = 10)
Catheter or surgical ablation (n = 6)
Antiarrhythmicsonly (n = 4)
Sra JS. Ann Intern Med. 1991;114:1013-1019.
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Risk of Mortality from Syncope Risk of Mortality from Syncope Based on Outcome of EP StudyBased on Outcome of EP Study
Bass EB. Am J Cardiol. 1988;62:1186-1191.
% T
ota
l Mo
rtal
ity
100
80
60
40
20
00 6 12 18 24 30 36 42 48 54 60
Months of Follow-Up
= Positive EPS Patients= Negative EPS Patients
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History of EP StudyHistory of EP Study19691969 His bundle electrogramHis bundle electrogram
1970s1970s Programmed electrical StimulationProgrammed electrical StimulationEndocardial mapping of Ventricular tachycardiaEndocardial mapping of Ventricular tachycardia
Surgical ablation of arrhythmiasSurgical ablation of arrhythmias
1980s1980sCatheter ablation of arrhythmias with DC currentCatheter ablation of arrhythmias with DC currentRadiofrequency catheter ablationRadiofrequency catheter ablationIntroduction of ICDIntroduction of ICD
1990s1990s
Newer mapping techniquesNewer mapping techniques
2000s2000s
19691969 His bundle electrogramHis bundle electrogram
1970s1970s Programmed electrical StimulationProgrammed electrical StimulationEndocardial mapping of Ventricular tachycardiaEndocardial mapping of Ventricular tachycardia
Guided treatment for arrhythmiasGuided treatment for arrhythmiasSurgical ablation of arrhythmiasSurgical ablation of arrhythmias
1980s1980sCatheter ablation of arrhythmias with DC currentCatheter ablation of arrhythmias with DC currentRadiofrequency catheter ablationRadiofrequency catheter ablationIntroduction of ICDIntroduction of ICD
CAST trial, IMPACT trialCAST trial, IMPACT trial1990s1990s
ESVEM trial, CASCADE, CMIAT, EMIAT, etc...ESVEM trial, CASCADE, CMIAT, EMIAT, etc...AVID trial, MADIT, MUSTTAVID trial, MADIT, MUSTT
Newer mapping techniquesNewer mapping techniques2000s2000s Expansion of indications for RFCAExpansion of indications for RFCA MADIT-II, SCD-HeftMADIT-II, SCD-Heft
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EPSEPSA crystal ball A crystal ball to see what lies ahead?to see what lies ahead?
ObservationObservationAnti-arrhythmic DrugsAnti-arrhythmic DrugsDevicesDevices DefibrillatorDefibrillator
PacemakerPacemaker
OperationOperationAblationAblation
Purpose of studyPurpose of study
Cost of TreatmentCost of TreatmentPatient’s lifePatient’s life
Can it be justified?Can it be justified?
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Treatment of ArrhythmiaTreatment of Arrhythmia