A Review of VT

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family, Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Oussama Wazni, MD, MBA:

Hello everyone and welcome once more to an EP podcast from the Cleveland Clinic. I'm Oussama Wazni, I'm the Section Head of Clinical Electrophysiology here at the Cleveland Clinic. And with me today, it's my honor to introduce you to Dr. Santangeli. He's our new director of the VT Center. So welcome Dr. Santangeli, and thank you for being here with us.

Pasquale Santangeli, MD, PhD:

Thank you, Dr. Wazni. It's a pleasure to be here and part of this group.

Oussama Wazni, MD, MBA:

So could you tell us, Dr. Santangeli, what is it about our VT Center that makes us special?

Pasquale Santangeli, MD, PhD:

Well, I mean, we are really specialized in the most complex VT ablation in particular and treatment of VT, but it's not just the ablation part. We really specialize in taking care of patients from the beginning to the end of that management pathway. So we have strong relationship with cardio genetics, with imaging, with CT surgery, and that makes the entire program extremely suitable for any patient really from the most complex, also, the least complex ones, where we can take care of the full spectrum of diseases associated with VT.

Oussama Wazni, MD, MBA:

That's very good. And could you tell us more about our collaboration with our heart failure colleagues in VT patients?

Pasquale Santangeli, MD, PhD:

Yes. One unique aspect about this program is that we do meet really as a team within the HVTI center to discuss what the pathway would be for each individual patient. We have a strong collaboration, again with Imaging, which is very important for pre-procedural planning. With the heart failure team in particular, as you mentioned, because we do know that some of these patients may have associated heart failure comorbidities, so we want to know really which way they're going in terms of their prognosis and what the best treatments are even after the ablation. So we take care of the ablation aspect, but it's really more about the entire patient.

Oussama Wazni, MD, MBA:

So could you just go with me, like for example, the process when a patient with ventricular tachycardia or VT storm, gets transferred to the Cleveland Clinic, what is it that we do for those patients? How do we take them from VT storm, for example, to ablation if that is the endpoint or through the medical therapy?

Pasquale Santangeli, MD, PhD:

Yes, there are different aspects to that. Of course, the getting rid of the VT storm, of course the primary endpoint for us. But before we get to that point, we really want to understand what the patient is in terms of the heart failure and other comorbidities. So we do discuss collegially within our section and also with other sections, heart failure, general cardiology, as well as imaging, what the treatment plan would be. And if we do involve CT surgery when necessary, specifically when a hemodynamic support is necessary, we have a plan of what may happen in case the patient decompensate during the procedure we already know. And so to provide optimal outcomes for those patients. And during the procedure, of course we try to eliminate all the inducible VTs together with the VT storm to maximize the outcome. But that can be done only if you have a strong collaboration with other sections.

Oussama Wazni, MD, MBA:

Yeah, no, we are really very lucky to have a comprehensive team in HVTI, in Cardiology and especially in Electrophysiology with surgeons with the heart failure specialists so that we can manage these patients comprehensively, whether it just needed a VT ablation or medical therapy or even destination therapy with LVADs or even transplant in some cases. So really in that respect, I think we're one of the most advanced centers in the world for this. Now, certain conditions are genetic or inherited. So could we just go over some of these etiologies and how we manage them?

Pasquale Santangeli, MD, PhD:

Yeah, thank you for asking this question. This is really one of the major focus for my clinical research. We do have a strong center for inherited cardiomyopathies and ARVC in particular, I'm talking about arrhythmogenic cardiomyopathies, left and right type of arrhythmogenic cardiomyopathy, brugada and long QT syndrome. And we do have a strong collaboration with cardio genetics. In fact, most of our patients with nonischemic cardiomyopathy at some point will undergo some form of genetic testing, which is so important. Not so much for the proband, but more for the family management. So it's been really something of unique, I would say to this group, the collaboration that we have so we can maximize and improve the outcomes for patients and their families.

Oussama Wazni, MD, MBA:

That's excellent. And finally, can you tell us about some new approaches in mapping and ablating, PVCs and VT in general?

Pasquale Santangeli, MD, PhD:

Yes. So we have two different types of struggles that we have for VT ablation and for mapping as well. The most important one is whenever we cannot map because of an inaccessible substrate in particular when it's intramural, so inside the septum and inside the free wall of the ventricles where we cannot access those. In those cases, we came up with some ways of mapping by using perforators of the veins or the coronary sinus. And occasionally it also becomes transarterial to deploy microcatheters in those areas. And if we do record activity of interest, then we have a new ways of ablating them by injecting, for example, alcohol. But we also do treat these cases with bipolar ablation occasionally, which is something that we also do here and other types of bailout strategies that we have available. So we really, that's one of the areas where we are working actively to improve the outcomes.

Pasquale Santangeli, MD, PhD:

And the other aspect will be the new approaches for one of the aspect that we are still really working out to improve the efficacy and safety of epicardial mapping. We come up with a new way of actually of accessing the pericardial space that is facilitated by CO2 injection, it's actually a technique that has been initially described in England, but brought here in the US by us, actually. And we had the most experience in the US in doing that. And this improves the efficacy and safety of this approach. So we can provide this very effectively and very safe to every patient really that needs it with minimal risk of complications.

Oussama Wazni, MD, MBA:

That is perfect, actually, that's one of the most complicated procedures that we do, and one with the most risk. So, any way we can do it to make it safer and easier is of course welcome. Also, our team is very involved in the new technologies and new energy sources for ablation, whether in the atrium or in the ventricle. So now we're talking about ventricular foci, but pulse field ablation, we're studying it also in our preclinical work with Dr. Santangeli and hopefully that will become online in the next few years. So thank you very much Dr. Santangeli, for being with us, for bringing this new comprehensive approach to management of ventricular tachycardia and PVCs, and follow us on some more new podcasts from EP at the Cleveland Clinic. Thank you very much.

Announcer:

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