1 A Stepwise Approach to the Management of Post

DOI: 10.1161/CIRCEP.113.000261
A Stepwise Approach to the Management of Post-Infarct Ventricular Tachycardia Using
Catheter Ablation as the First Line Treatment: A Single Center Experience
Running title: Pauriah et al.; Post-Infarct VT ablation as a first line treatment
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Maheshwar Pauriah, MD1; Gabriel Cismaru, MD1; Isabelle Magnin-Poull,
Mag
gnin-Poull,, MD
D1;
Marius Andronache, MD, PhD1; Jean-Marc Sellal, MD1; Jérôme
me Schwartz,
Sch
chwa
wart
wa
rtz,
rt
z, MD
MD1;
Béatrice Brembilla-Perrot, MD1; Nicolas Sadoul, MD1; Etienne
enne Al
Alio
Aliot,
iott M
io
MD
D1;
u, MD, PhD1,22
Christian de Chillou
Chillou,
1
CHU
CH
HU de
de Nancy,
Nancy
cy, D
Department
epart
rttment
me off Ca
C
Cardiology,
arddio
i logy, University
Univ
Un
iv
iversi
v siity H
Hospital
ospita
tall Na
ta
N
Nancy;
ncy;
2
IADI
IA
D - IN
DI
IINSERM,
SERM
SE
RM,, U947,
RM
U9947
4 , Nancy,
Nanc
Na
n y,
nc
y, France
Fra
ranc
n e
nc
Address for Correspondence
Christian de Chillou, MD, PhD
Département de Cardiologie
Hôpitaux de Brabois,
1, rue du Morvan
54511Vandoeuvre lès Nancy
France
Tel: (33) 3 83 15 74 43
Fax : (33) 3 83 15 49 17
E-mail: c.dechillou@chu-nancy.fr
Journal Subject Codes: [5] Arrhythmias, clinical electrophysiology, drugs; [22]
Ablation/ICD/surgery; [106] Electrophysiology
1
DOI: 10.1161/CIRCEP.113.000261
Abstract:
Background - The occurrence of ventricular tachycardia (VT) following myocardial infarction
(MI) is associated with poorer prognosis. In such patients, implantable cardioverter-defibrillators
(ICD) are recommended. Catheter ablation of VT is currently recommended only as an
adjunctive therapy. Whether a successful VT ablation alone might be a viable strategy in some of
these patients, however, remains unknown. The aim of the present study was to evaluate this
strategy.
Methods and Results - Between January 2002 and December 2011, 189 patients with
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
cardiomyopathy underwent 259 VT ablations in our centre. 45 patients ((mean age
g 65.2±9.6
years, 91% males) with a history of MI and mean left ventricular ejection
fraction
39.7±9.7%
ionn fr
io
frac
acti
ac
tion
ti
on ooff 39
39.7
.7±
.7
±
matched the study criteria and were included in this analysis. Acute success
uccesss was
was oobtained
btai
bt
aine
ai
nedd in
ne
40/45 (88.9%).
During
9%).
9%
%). D
urin
ur
ingg a fo
in
ffollow-up,
llow-up, based on our stepwise
sttep
e wise algorithm
h [[utilising
utilising acute success,
succes
repeat electrophysiological
trophysiological
tr
rophysiologi
giica
c l study
sttud
udyy (EPS)
(E
EPS
PS)) and
a d recurrence
an
recu
cu
urren
nce ooff VT
V
VT],
], 119/45
9/455 ((42.2%)
9/
9/45
42.2
42
.22%) uunderwent
ndder
erwe
went
we
nt ICD
I
implantation.
mortality
on. During
on
Duringg a median
mediaan follow-up
foll
llow
ll
ow-uup of
ow
of 4.55 (IQR:
(IQR:
R 2.1-7.0)
2.1
.1-7..0) years,
yeaars, aall-cause
ll-ca
caus
ca
u e mo
m
rtaalityy
occurred in
n 14/45
14/4
/4
45 (31.1%)
( 1.1%)
(3
1.. ) of ppatients.
atient
nts. Usingg m
multivariate
u tiiva
ul
vari
r ate Cox
Co regression
regr
g esssion analysis,
ana
n ly
ysi
s s,, age
g [hazard
[haz
[haz
ratio (HR)=1.13,
independent
=1.13,
=1.1
13, 95%
95% confidence
con
onfi
on
fide
fi
d nce in
iinterval
t rvall (CI):
te
(CI
CI):
) 1.03-1.22,
):
1.003-11.22
22,, p=0.007]
p 0.00007]
p=
7 was
was tthe
he oonly
nlly in
inde
independ
depe
de
p nd
pe
predictor off m
[HR=0.54,
95%
mortality
orta
or
tali
lity
ty w
while
hile
hi
l IICD
le
CD iimplantation
mplla
mp
lant
ntat
tat
atio
tio
i n was
was no
nott [H
HR=
R 0.
0 54
54,, 95
5% CI
CI:: 0.18-1.64,
00..18
18-1
-11.6
.64,
4, p=0.28)
pp=0.2
=0
0.2
Conclusions - Our results suggest that a stepwise approach to the management of VT with
ablation as a first line treatment in post-infarct patients presenting with VT might be a reasonable
option. Further studies are required to confirm these results.
Keywords: ventricular tachycardia, catheter ablation, ischaemic cardiomyopathy, programmed
electrical stimulation, implantable cardioverter-defibrillator
2
DOI: 10.1161/CIRCEP.113.000261
Introduction
In patients with ischemic cardiomyopathy (ICM), ventricular tachycardia (VT) is associated with
poor long-term outcomes1. Three secondary prevention studies have shown the unequivocal
benefit of implantable cardioverter-defibrillators (ICD) in patients with previous myocardial
infarction (MI) and impaired left ventricular ejection fraction (LVEF)2-4. These studies, however,
excluded patients with stable VT or with LVEF>40%. Analysis from the Anti-arrhythmics
versus Implantable Defibrillators (AVID) registry5, however, suggests that clinically wellDownloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
tolerated VT carries a poor prognosis as well. ICDs are therefore recommended
mmended in pa
ppatients
tien
en
nts
t with
previous MI and sustained VT6. While ICDs improve overall survival, theyy do
d not
nott eliminate
eli
limi
minnat
mi
nat the
esponsible
esp
pon
onsi
siiblle for
f r sustained
fo
s stained arrhythmia. ICD
su
D without
w thout ablation
wi
ablatiion carries
carries a higher risk of
o
substrate responsible
shocks7,8 and
ndd shocks are as
n
associated
ssoociiated
d withh de
decreased
ecreaaseed quality
qualit
qu
ityy ooff lifee aand
it
nd in
increased
ncrreasedd in
nm
mortality
ortaality9. VT
h other
oth
ther hand,
handd, reduces
reduces
d
or even aabolishes
bolishhes VT
bo
boli
VT eepisodes
pis
isoddess iin
n some ppatients.
atientts. C
at
ati
Curren
urren
ablation, onn the
or
Currently,
guidelines sug
suggest
gge
g st that
thhat VT ablation
abl
blatio
bl
i n to
t be used
used
d as an adj
adjunct
djunctt to IC
dj
ICD
D100. Itt is
is nott known
k ow
kn
wn whether
w ethh
wh
some patients
nts
nt
t presenting
ti with
ithh VT can be
it
b ttreated
r tedd bby ablation
blati
tio alone
al
alone.
l
In our centre, we have been routinely performing VT ablation as a first line treatment in
patients with ICM presenting with VT. Patients with a successful ablation, defined as the noninducibility of all VTs at the end of the index procedure followed by a negative
electrophysiological study (EPS) within 3 months, do not have an ICD implanted. The aim of
this study was, therefore, to evaluate this stepwise approach to VT management by comparing
the long-term outcomes of those who received an ICD with those who did not.
Methods
2.1 Study Population
Between January 2002 and April 2011, a total of 189 patients with structural heart disease
3
DOI: 10.1161/CIRCEP.113.000261
underwent 259 VT ablations in our centre: [145 with ischaemic cardiomyopathy (ICM), 17 with
dilated cardiomyopathy (DCM), and 18 with arrythmogenic right ventricular dysplasia (ARVD)].
In this study, we included patients with the following criteria: 1) previous history of myocardial
infarct, 2) documented monomorphic VT, 3) no prior ICD, 4) repeat or planned EPS after first
procedure and 5) follow-up of at least 1 year after ablation or until censoring at the time of death.
Patients were excluded if 1) initial presentation was cardiac arrest and/or 2) patients with severe
co-morbidities where a clinical decision was made not to implant an ICD. Of the 145 patients
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
with ICM, 74 did not have an ICD prior to VT ablation and 45 fulfilled
d the criteria for the
th
he study.
s
All patients provided informed consent and all procedures were conformed
rmed
d ttoo the
the CHU-Nancy
CHUCH
U Na
UNa
guidelines.
2.2 Electrophysiological
Study,
Mapping,
Ablation
oph
oph
physiologica
al Stud
ud
dy, M
appi
piingg, and
d Ab
bla
ation
on
n
Electrophysiological
previously
ysiological
ysiol
log
ogic
ical
ical
a study
d (EPS),
(EP
EPS)
S , mapping,
maapping, and
andd catheter
catthetterr ab
abla
ablation
l ti
la
tionn were
were perf
performed
for
orm
med as pre
previo
vio
i
described111. Briefly,
B iefl
Br
fly,
fl
y a bbipolar
y,
ip
pollar catheter
cathe
h te
t r was iinserted
nserted
d vi
via
ia tthe
he ffemoral
emoral
al vei
vein
einn andd po
ei
ppositioned
siti
tiion
oned
ed at the
t
right ventricular
iic llar
a apex
ape and
ndd used
sed
d primaril
primarily
im il for
fo VT iinduction
ind
ndd ction
ti with
ithh the
it
th application
pli
licati
tio off upp tto
o3
extrastimuli during spontaneous rhythm then during paced rhythm (600-ms and then 400-ms
basic cycle length). This programmed electrical stimulation (PES) protocol was delivered
through an external stimulator (Biotronik UHS 20, Biotronik Inc) with a 2-ms pulse width at
twice the diastolic threshold. Failure to induce a sustained VT promoted the same protocol in the
right ventricular outflow tract.
An 8F or 7F, 8mm-tip or 3.5mm-irrigated tip catheter (NAVI-STAR® or
THERMOCOOL®, Biosense-Webster, Johnson & Johnson) was used for mapping and ablation
of VT circuits. Access to the left ventricle was achieved retrogradely across the aortic valve or
through trans-atrial septal puncture.
4
DOI: 10.1161/CIRCEP.113.000261
The electrical reference was chosen as a morphologically stable and regular ventricular
electrogram that was obtained from either an endocardial or surface lead, with the choice
determined by a QRS complex with a sharp apex and a strong positive (or negative) deflection
during VT. The width of the window of interest varied from one VT map to another, inasmuch as
it was correlated with the VT cycle length with the following formula: window of interest
ZLGWK 97F\FOHOHQJWKíPV7Ke middle of the window of interest was selected to coincide
with the electrical reference. The local activation time for each endocardial position under the
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
mapping catheter was calculated as the interval between the electrical reference and thee ppeak
ea
deflection of the mapping bipolar electrogram. In case of double potentials,
the
earliest
ntialss, th
he ea
earl
rllie
iest
st ppeak
ea
ea
deflection of
doublet
was
electrograms
o the
th
he do
doub
uble
ub
l tw
as used. Long-duration fractionated
fractionated elec
e trog
ograms were marked tto the
og
highest peaklet.
akleet.
ak
Thee left
plotted
clinical
ft vventricle
en
ent
ntricle
l was pl
lotted
ed
d dduring
uring th
thee induced
indu
d ced cl
cli
iniical VT
V by
by dragging
d ag
dr
ggi
ging
ng tthe
h catheter
he
catthett
over the endocardium.
VT
with
ventricular
the
right
ventricle
n
ndocardi
dium. Inn case off a V
di
T wi
ith
h a right
riigh
ght vent
tricullar septal
sept
pttall exit,
exi
xit, th
xi
he ri
igh
ht ve
vent
nttricl was
mapped as well
the VT iisthmus,
it,
ell
ll tto ch
check
h k whether
hhether
eth
the th
isthm
sth
thm s or a partt off iit
t was
as llocated
o tedd in
in the
the right
ight
ht
ventricle. Infarct regions were sought first, and more data points (target filling threshold set to
10) were acquired in and around these areas. Refining the area under investigation relied on the
usual clinical indicators, such as sinus rhythm analysis, echocardiography, and VT morphology
on the 12-lead ECG. More data points were acquired in the zones defined as scarified, with lowamplitude potentials, with diastolic electrograms, or with double potentials. These areas were
probed because they are important for the identification of the re-entrant circuit. The mapping
procedure was terminated when a density of points was achieved that was sufficient enough to
allow an understanding of the VT circuit. The resulting reentrant circuit was considered to be the
spatially shortest route of unidirectional activation encompassing a full range of mapped
5
DOI: 10.1161/CIRCEP.113.000261
activation times (>90% of the tachycardia cycle length) and returning to the site of earliest
activation. Conventional mapping, including pace mapping during sinus rhythm, entrainment
manoeuvres and post-pacing interval analysis12 during VT, were not performed routinely since
VT isthmus definition was based upon VT activation time mapping. Once defined, linear RF
lesions were placed so as to transect the VT isthmus in case of mappable VTs. For unmappable
VTs, ablation sites were required to have abnormal low-amplitude electrograms, electrograms
with double potentials, wide fractionated potentials, or isolated late potentials during sinus or
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
paced rhythm. Pacemapping during sinus rhythm and measurement off the stimulus-to-QR
stimulus-to-QRS
QRS
QR
S
interval were then used to unmask VT isthmuses and determine ablation
on sit
sites
ittes13 ooff un
ites
unma
unmappable
maapp
ppa
VTs.
Systemic
stttemic
emic anticoagulation
em
anticoagu
gulattioon was
was achieved
ach
ch
hieeved with
w th heparin
wi
hepar
arin
in (initial
(iinitial
inittiaal bolus
booluss of
of 500 U/kg
U/
U/kg IV
V followed
fol
fol
20000 U per
pe hour)
h ur)) throughout
ho
throug
th
h gho
h ut the procedure.
pro
roccedu
d re. Se
Sed
Sedation
dati
dati
da
tioon w
was
as obt
obtained
btaine
bt
nedd with
ne
t 110
th
0 mg IV
by 1000 to 2000
nalbuphine,
e wi
e,
with
ithh in
iincremental
crem
menta
t l ddoses
oses att 5 mgg as necessary
necessary.
y.
l ttii and
dE
d i t
2.3 RF Ablation
End-point
Identification of the ablation site was based on analysis of the 3D map. The anode was a 575-cm2
back plate placed under the patient’s left shoulder. RF ablation was performed with a 550-kHz
RF Stockert-Cordis generator. The RF energy was delivered in a temperature-controlled mode
for 60 to 120 seconds at each ablation site with a maximal temperature/power target of
45°C/40W for 3.5-mm tips (55°C/75W for 8-mm tips). Acute success was defined as a negative
EPS at the end of the procedure. Successful VT ablation was defined as acute success and a
negative repeat EPS at 2-3 months. Negative EPS was defined as absence of inducibility of any
sustained monomorphic VT with a rate <270/min. Induction of monomorphic very fast VT
UDWH•PLQDVZHOODVSRO\PRUSKLF97RU9)ZHUHQRWGHILQHGDVSRVLWLYH(36
6
DOI: 10.1161/CIRCEP.113.000261
2.4 Management after Ablation
After ablation, patients were monitored for 72 hours by telemetry. Transthoracic
echocardiography was performed within 2 days after ablation. Patients were then discharged and
followed on an outpatient basis with clinical evaluation and 24-hour Holter recordings performed
regularly.
All patients were evaluated routinely at 6-8 weeks post procedure and the 3 to 6 months
intervals. Patients with ICD underwent interrogation every 6 months and all recorded arrhythmic
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
episodes were collected and analysed. Follow-up data, including mortality
available
alityy was availabl
le oon all
patients.
2.5 Stepwise
i aapproach
ise
p ro
pp
oac
ach al
algorithm
All patientss underwent
complete
unnderwent V
VT
T ab
ablation
blaation
on with
witth the
th
he primary
prim
im
maryy aaim
im
m off com
om
mplete
etee aabolition
boolitionn of
of all
alll VTs.
VTs
Ts. After
a successful
EPS
VT
ul procedure,
prooce
cedu
dure, an E
du
PS was pperformed
er med aatt 3 mont
erform
months
ths and
and further
fur
urth
th
her ablation
ablat
atio
at
ion carried
io
carriiedd iff V
was induced.
Before
this
repeat
EPS,
antiarrhythmic
withdrawn
halfe Be
ed.
B
fore thi
hiss repe
hi
p at E
PS, anti
PS
iarrhy
hyth
thmi
h ic ddrugs
ruggs were w
ithd
hdra
raawn ffor
or at lleast
east
ea
s 5 ha
st
a
lives in all patients,
which
Repeat
patients
ati
tientt except
e cept
ptt amiodarone
miiodd
hhich
ichh was
as st
stopped
t
d att lleast
stt one month
th before.
bbefore
eff e R
Repe
e
EPS was continued after a successful ablation until the study was negative or an ICD was
implanted. The stepwise algorithm is shown in Figure 1. ICD was implanted if any of both
following criteria were present:
(MHFWLRQ)UDFWLRQ”LQSDWLHQWVZKRXQGHUZHQW97DEODWLRQDIWHUWKHSXEOLFDWLRQRI
the European Society of Cardiology Guidelines6 for ICD implantation (i.e.: patients with
EF<35% who underwent VT ablation prior to this publication did not receive an ICD if they had
successful ablation).
2) A fast VT (VT with a shorter cycle length than the clinical VT) was inducible at the
end of the procedure.
7
DOI: 10.1161/CIRCEP.113.000261
2.6 Statistical Analysis
All variables were tested for normal distribution based on the visual inspection of the frequency
histogram and Shapiro-Wilk test. Normal data are presented as mean ± SD and categorical
variables are expressed as percentages. Non Gaussian data are presented as median [interquartile
range (IQR)]. For qualitative data, absolute and relative frequencies are shown. Comparisons
between groups were made by Ȥ2 test or Fisher exact test for categorical variables and unpaired t
test for normally distributed variables. Survival analysis was carried out using the nonDownloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
parametric Kaplan-Meier curve and differences between survival curves
es was analysed
analys
y ed uusing
sinn the
si
Log rank test. Multivariate Cox regression analysis was carried out to provide
hazard
provi
viide
d aadjusted
djus
dj
uste
t d ha
te
haz
z
ratio (HR). All
tailed,
statistical
inferred
at
All probability
p obbab
pr
abilit
ityy values are presented as 2 ta
it
ailed, with sta
t tist
sttical significance infe
e
p<0.05. Analyses
Chicago,
nalyses
na
alyses were pperformed
errforrmed uusing
singg SP
SPSS
PSS for
for w
windows
in
ndoows vversion
erssioon 17.
17.0
7.0 (S
((SPSS
PSS
S In
Inc
Inc.,
c.,, Ch
Chica
hicca
ILL).
Results
3.1 Patient Characteristics
The study population consists of forty-five patients (mean age 65.2±9.6 years, 91% males) with a
previous history myocardial infarct (Table 1). Thirty-two (71.1%) patients had a previous
inferior MI and the left ventricular ejection fraction was 40% (IQR= 30-50%). Twenty-seven
(60%) presented with a combination of shortness of breath or palpitations, 6 (13.3%) with chest
pain, 5 (11.1%) patients with syncope, 1 (2.2%) with cardiogenic shock and the rest with a
combination of these. The median VT cycle length was 370 ms at presentation and varied from
240 to 664ms. Table 2 shows the characteristics of the different VTs during ablation.
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DOI: 10.1161/CIRCEP.113.000261
3.2 Ablation Results
success was obtained in 40 (88.9%) after first ablation. Of the remaining 5 patients, 3 patients
had fast VT at the end of the procedure and had an ICD implanted and the other 2 patients had
repeat EPS (Figure 1).
At follow-up and before repeat EPS, 1 patient died of heart failure and there was VT
recurrence in 3 (7.5%). Repeat EPS was performed in 36 patients and VT was inducible in 13
(36.1%). For patients with a negative EPS, 1 (4.5%) had recurrent VT. Based on our algorithm,
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
ICD was implanted in 19 (42.2%) patients.
Complications occurred in 4 patients including two cerebrovascular
cular
ar aaccidents
ccid
cc
iden
id
ents
ts ((CVA),
CVA
CV
A one
femoral haematoma
emat
em
atom
o a an
om
aand
nd on
oonee complete heart block.
3.3 ICD Therapies
Therapies and
d Mortality
Mo
ortalit
rtt it
ityy
During a media
median
follow-up
(IQR=
without
m
i n fo
foll
l ow-up off 4.5
ll
4.5 years
year
ye
a s (IQR
ar
QR= 2.
QR
22.1-7.0),
1-7.
7 0)
0), th
theree we
were
re 5 ddeaths
eath
hs in
n the group w
an ICD and
d 9 in
in the
th
he ICD
ICD group.
g oup.
gr
p Patients
Patiients with
wiith
h an ICD
IC
CD had
h d a lower
ha
lowerr median
m di
me
diaan survivall as
as compared
ccomp
omp
to patients without
statistically
significant
iitho
th t an ICD,
IICD
CD although
alth
altho
lth gh
h the
the results
res llts
ts were
ere nott st
statisticall
tati
tisti
ti ll si
i if
ifiic t (l
(log rank
k ttest, p
= 0.11) (Figure 2). The mean age in the ICD vs. no ICD group were 63.4±10.4 years vs.
67.2±8.6 years, p=0.18, and median left ventricular ejection fraction (%) was 40 (30-44) vs. 45
(30-50), p=0.21. ICD implantation was not associated with improved survival [unadjusted
HR=0.42 (0.14-1.25), p=0.11]. Using Cox regression analysis with age and ICD implantation as
covariates, only age was an independent predictor of mortality [HR=1.13, 95% confidence
interval (CI): 1.03-1.22, p=0.007] while ICD implantation was not [HR=0.54, 95% CI: 0.181.64, p=0.28). A similar trend was obtained when cardiovascular (CV) mortality (4 CV deaths in
the group without an ICD and 6 in the ICD group) was compared (Figure 3) between patients
with and those without an ICD. The causes of CV deaths were : 1) heart failure [3 in the no ICD
9
DOI: 10.1161/CIRCEP.113.000261
group and 3 in the ICD group], 2) intractable VT/VF [2 in the ICD group], 3) sudden death [1 in
the no ICD group] and 4) cardiac tamponade following ICD implantation in one patient.
VT with syncope or cardiovascular compromise: A subgroup of patients (10/45) presented
with VT with syncope or significant cardiovascular compromise (pre-syncope, pulmonary edema
or cardiogenic shock). They all underwent the same protocol of VT ablation and ablation guided
ICD implantation. The results of these patients are shown in Table 3.
Arrhythmic Death: 2 patients in the ICD group died due to intractable VT/VF and 1 patient in
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
the group without ICD had a sudden death. This was a 76 year-old man,
n, with a LVEF off 50%,
50
who initially presented with a VT cycle length of 353 ms and had an acutel
acutely
successful
elly su
succ
cces
essf
sful
full aablation.
bl
bl
ICD Therapies
apie
ap
iess
In patients with
was
delivered
patients,
with
with an ICD, therapy
thheraapy for
or VT
T wa
as del
livvereed in
n 8/19
8/1
19 (42.1%)
(4422.1%
.1%
%) pa
ati
tients,, w
ith 7 patients
ppati
ati
having had
therapies.
d 2 or mo
more
o the
h rapi
piies.
Discussion
n
The aim of this study was to look at the results of a stepwise approach for the management of
patients with ICM presenting with VT with ablation as an initial treatment strategy. ICD was
implanted based on a predefined decision tree taking into consideration acute success,
inducibility at repeat EPS and recurrence. To our knowledge, this is the first study to look at such
an approach. This study has a number of interesting findings. Firstly, it suggests that a strategy of
successful VT ablation, defined as non-inducibility of all VTs followed by a negative EPS, in
patients with post-infarct VT is safe, feasible and can be used as a means to risk stratify patients
as to the implantation of ICD. Secondly, the mortality rate in the successful ablation group was
not higher than the ICD group. Although the numbers are limited, this strategy does not seem
harmful even in patients presenting with haemodynamically unstable VT.
10
DOI: 10.1161/CIRCEP.113.000261
In patients with ischemic cardiomyopathy, ventricular tachycardia (VT) carries a poor
prognosis1,2,5. Various studies have shown the superiority of ICD therapy compared to medical
therapy on long term outcomes in such patients2-4. Devices, however, do not take away the
arrhythmic substrate capable of sustaining a VT circuit. They merely provide therapy for fast
heart rates which the ICD recognises as VT or VF based on predefined algorithms. VT ablation,
on the other hand targets the substrate responsible for the arrhythmia mechanism. Two
randomised control trials have shown that catheter ablation reduces ICD therapies, including
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
shocks7,8 in patients with ICM and VT. The question that arises therefore
fore is whether a ssuccessful
ucc
uc
ablation is enough, at least in a subgroup of patients. One problem withh “successful”
“suucc
cces
essf
sffull” VT aablation
b
14 18
is the high rate
te of
of recurrence
reecu
curren
ence varying between 20 an
en
andd 44 %14-18
. Inn a ggroup
r up of patients with
ro
ischemic heart
eart
rt disease and
nd haemodynamically
hae
aemody
dyynami
m caally we
well-to
well-tolerated
olera
rate
teed VT
VT,
T, Del
Della
llaa Be
B
Bella
lla ett aal.
l.144 sho
showed
hoowe that
n resu
sult
su
lted in th
lted
the ab
bolit
li ion of the ttargeted
arge
ar
get
etedd VT
T iin
n 73
73%
% of ppatients.
attients. A
lthhoughh the
lt
th
he
VT ablation
resulted
abolition
Although
recurrence rate was substantial
subs
bsta
bs
tanttiall (27%),
ta
(27%
(2
7%
%),
) onl
only
ly three
th
hree patients
p tients
pa
i
(2.5%)
(2.
2 5%
%) di
ddied
ed
d ssuddenly.
udddenlly.
ud
y O
Our
ur sstudy
tu
udyy is
similar to the
hhee study
stt d bby D
Della
ell
ll B
Bella
ell
ll ett al.
all 14 iinn that
thatt wee looked
l kedd att a similar
imil
il cohort
ohh t off patients
patients.
ati
tientt
However, in the above study, repeat VT stimulation study was not carried out. Moreover, ICD
was implanted in 11% in the study population and they were prior to the VT ablation. The same
group19 showed that a negative EPS after VT ablation for VT storm was a predictor of absence of
VT recurrence over a long period of time. It is possible that incomplete ablation and/or oedema
might limit the predictive value of EPS immediately post ablation and therefore it is possible that
an EPS remote from the ablation time provide a better answer. In patients with a structural heart
disease, Frankel et al.20 showed that a negative EPS performed 3.1±2.1 days after ablation
predicted >80% VT-free survival over 1 year follow up. We arbitrarily chose a 3 month period to
allow the scar to “mature”. Our study therefore adds further to the current understanding.
11
DOI: 10.1161/CIRCEP.113.000261
However, given the high recurrence rates, additional substrate based ablation might provide even
better results.
There was a trend towards a survival benefit in the successful VT ablation group
compared to the group with ICD, although the results were not statistically significant. Several
trials have shown that ICD therapies are associated with mortality and morbidity, and therefore it
is conceivable that successful ablation and abolition of substrate for sustained VT might lower
mortality.
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
In addition, there is also an economic argument in favour of thee stepw
stepwise
approach
p ise ap
ppr
p oaach tto VT
ablation. ICDs are costly and therefore this strategy might allow us to use limited
limi
mit
ited
d resources
res
esou
ourc
rcees in a
rc
more cost effective
way.
e fe
effe
fect
ctiv
ct
ivee wa
iv
w
y.
Limitations
ns
ns
This study is no
not
controlled
trial
therefore
inherent
limitations
ot a rrandomised
anddomis
i ed
d control
ollled tria
ol
iaal an
andd th
theref
for
ore th
the in
inhe
herentt lim
he
mittat
ations off
observational
patients
nal stud
studies
dies apply.
appl
ap
p y.
pl
y Patient
Patie
i nt groups
groupps are not homogeneous.
homoge
g neous. Decision
Decis
ission on whether
whe
h th
ther
e ppati
er
ati
had an ICD
conceivable
that
D was
as not
ott random
do bbutt based
ba d on a ddecision
isiio tree.
ttree
r It is
i therefore
th eff
concei
eii able
bl th
att tthe
he
patient group without an ICD represented a less healthy cohort. However, the mortality
difference demonstrated would argue against this. It can be argued that physicians may have felt
more comfortable not implanting an ICD in certain patients and this would have created an
inherent bias. However, this is unlikely, in our opinion, given that this decision was made on a
predefined algorithm.
Secondly, it is a small study, and analysis of subgroups inherently, makes the groups
smaller.
Thirdly, the exact timing of a repeat VT stimulation study to confirm non-inducibility is
unknown. We used a 3-month window based on experience.
12
DOI: 10.1161/CIRCEP.113.000261
Fourth, the only endpoint of the study was prevention of VT inducibility. Whether
modification of the arrhythmia substrate was achieved cannot be proven.
Finally, the results of this observational study need to be verified in a randomised
controlled trial (RCT). We appreciate that it may take a long time for such a RCT to be carried
out, mainly because of the current guidelines.
Conclusions
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
The results of this observational study suggest that a strategy of VT ablation and ablation gguided
ICD implantation might be a reasonable option in selected patients with
previous
MI.
thh pr
rev
evio
ious
io
us M
I
I.
Conflict off Interest
Disclosures:
Chillou,
lectures
In
D
isscl
clossur
ures
es:: Drr ddee Ch
es
Chil
i lo
ou, Andronache
And
ndrona
naach
nach
chee and
an
nd Aliot
Alio
Al
io
ot have
haave received
rec
ecei
eive
ei
vedd le
ve
lectu
u
fees from Bi
Biosense
Webster
annual
USD
B
iossense Webst
ter ffor
or lesss than 10,0000 annu
nual U
SD
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15
DOI: 10.1161/CIRCEP.113.000261
Table 1: Clinical Characteristics
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Age (years)
Sex (% male)
Ejection Fraction (%)
History of AF (%)
History of CABG (%)
History of PTCA / stenting (%)
Chronic renal failure (%)
NYHA (%)
I
II
III
In
nfarct (%)
Location off Infarct
n eri
nte
rior
or
Anterior
f
ferior
r/P
/ osteeri
r or
Inferior/Posterior
ce ((%)
%)
VT tolerance
Fairr
Poor
Syncope
Amiodarone prior to ablation (%)
Amiodarone post ablation* (%)
ICD Group
n= 19
No ICD group
n= 26
P
Value
63.4 ± 10.4
16 (84.2)
40 (30-44)
4 (21.0)
6 (31.5)
4 (21.0)
2 (10.5)
67.2 ± 8.6
25 (96.2)
45 (30-50)
3 (11.5)
8 (30.8)
9 (34.6)
3 (11.5)
0.18
0.20
0.24
0.43
0.95
0.51
0.92
0.32
0.
32
1 (5.3)
17 (89.4)
1 (5.3)
4 (15.4)
18 (69.2)
( 5.4)
(1
4)
4 (15.4)
0.19
19
3 (15.8)
(115.8))
16 (84.2)
(84.22)
(334.
4 6)
9 (34.6)
(65.4))
17 (65.4)
0 31
0.
0.31
14 (73.7)
(73
73.7
.7))
.7
4 (21.1)
1 (5.3)
11 (57.9)
10 (52.6)
2 (80.8)
(80
80.8
. )
.8
21
1 (3.8)
4 (15.4)
12 (46.2)
7(26.9)
0.55
0.07
AF: Atrial Fibrillation, CABG: coronary artery bypass grafting, ICD: Intra-cardiac defibrillator, NYHA:
New York Heart Association, PTCA: Percutaneous Transluminal Coronary Angioplasty, *: Treatment at
hospital discharge after the first procedure
VT: ventricular tachycardia
VT Tolerance:
Fair: VT without cardiovascular compromise
Poor: VT and cardiovascular compromise (i.e.: pre-syncope, pulmonary edema or cardiogenic shock)
16
DOI: 10.1161/CIRCEP.113.000261
Table 2: Ablation & Ventricular Tachycardia Characteristics
ICD Group
n= 19
1 (IQR 1-2)
No ICD group
n= 26
1 (IQR 1-2)
P Value
Number of different VTs at first
ablation
Epicardial ablation
1 (IQR 1-2)
1 (IQR 1-3)
0.57
0 (0.0)
0 (0.0)
NA
Entrainment12 (% YES*)
0(0)
3 (11.5)
0.25
Pacemapping (%YES*)
10(52.6)
20(76.9)
0.16
VT termination during RF
application (%)
5(26.3)
8 (30.8)
0.51
Abolition of post systolic potentials
(% YES**))
3(15.8)
8 (30.8)
00.32
0.
32
Procedure Du
D
Dur
Duration
ration (mi
(minutes)
inu
nutees)
221±
22
221±76
1 766
1±
2242±61
24
2±
±61
6
00.73
0.
73
Number of ablation procedures
0.22
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
ICD: Intra-cardiac
ardiac defibrilla
ar
defibrillator,
ato
or, N
NA:
A: non
non-applicable,
on
n-applicaablle, NS:
NS
S: non-significant,
no
on-sig
gni
nifi
fiica
cant,, RF:
RF: radiofrequency,
raddioofre
requen
re
ncy
cy, VT:
VT: ventricular
ventt
ve
ppercentage
rcenta
rc
tage
ta
ge of ppatients
ge
atiien
nts in
n wh
whom
om
mV
T en
ent
trai
ainm
nmeent an
and/
d oorr ppacemapping
d/
acem
ac
e ap
em
appiingg during
durin
ng si
ssinus
nuss rh
hyt
ythm
hm were
tachycardia, *: pe
VT
entrainment
and/or
rhythm
h VT isthmus, **: percentage off patients in wh
hom ab
bolition of po
ppost
st systolic poten
used to help unmaskk the
whom
abolition
potentials
(recorded on
was
n sinus
us rrhythm
hyth
hy
thm
th
m EG
EGM)
M)) w
as pperformed
erfo
er
form
fo
rm
med in
in addition
additiion
ad
o to
to VT isthmus
ist
sthm
hmus
hm
us ttrans-section
rans
ra
nss-se
sect
ctio
ct
io
on
Table 3: Clinical characteristics and outcomes in patients presenting with VT and cardiovascular
compromise prior to ablation
VT
ICD
Gender Age LVEF tolerance
NYHA Implanted Death Death Cause
M
63
42
POOR
2
YES
YES Bladder Cancer
M
64
46
POOR
2
YES
YES Unknown
M
80
40
POOR
2
YES
YES Heart Failure
M
75
30
POOR
3
NO
YES Heart Failure
M
71
30
POOR
2
YES
YES Untractable VT/VF
M
78
20
SYNCOPE
3
YES
YES Heart Failure
M
51
60
SYNCOPE
2
NO
NO
NA
M
68
30
SYNCOPE
2
NO
YES Heart Failure
M
68
45
SYNCOPE
2
NO
NO
NA
F
74
30
SYNCOPE
2
NO
NO
NA
ICD: Implantable Cardioverter Defibrillator, CVA: Cerebrovascular Accident, NYHA: New York Heart
Association, VT Ventricular Tachycardia, LVEF: Left Ventricular Ejection Fraction, NA: non-applicable
(patient alive)
*POOR: patients presenting with VT and cardiovascular compromise (i.e.: pre-syncope, pulmonary edema or
cardiogenic shock)
17
DOI: 10.1161/CIRCEP.113.000261
Figure Legends:
Figure 1: Stepwise Approach to the management of patients with Ischaemic Cardiomyopathy
and Ventricular Tachycardia.
CRT: Cardiac Resynchronisation Therapy, EP: Electrophysiology, ICD: Implantable
Cardioverter Defibrillator, VT: Ventricular Tachycardia. Well tolerated ventricular tachycardia
was defined as VT without cardiovascular compromise (i.e.: pre-syncope, pulmonary edema or
cardiogenic shock) and with no requirement of an immediate DC cardioversion.
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Figure 2: Kaplan-Meier Survival Curves for Patients with and withoutt ICD
D
Figure 3: K
Kaplan-Meier
Survival
cardiovascular
patients
with
and
without
aplan-Meier S
urvvivval free
frree ffrom
r m card
ro
diovaascul
ullarr ddeath
eath
h iin
n pa
atien
nts wit
itth an
nd w
ith
th
ho
ICD.
ICD: Implantable
a ble
antab
l C
Cardioverter
ardi
diov
di
overter D
ov
Defibrillator
efi
fibr
fi
b illato
t r
18
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45 patients with monomorphic VT and no ICD
1 patient died of heart failure, prior to
repeat EPS
Acute Success, n=40
Unsuccessful, n=5
Repeat EPS within 3 months, n=36
Recurrence of VT prior to EPS,
n=3
No VT Inducible,
n=23
Are all the remaining VTs
well Tolerated?
VT inducible,
n=13
Yes, n=2
Î Repeat EPS
No, n=3
Repeat Ablation
Acute Success
and Negative
repeat EPS, n=0
Recurrence of
VT @follow-up,
n=1
No VT
Recurrence
n=22
Are all the VTs well
tolerated?
Yes, n=6
Are all the VTs
s
well tolerated?
?
N
No,
o, n=7
ICD
impl
implanted,
pla
pl
anted,
n
n=3
No ICD
ICD,
D,
n=22
R
Repeat
e
Ablation
n=
n=2
Repe
Repeat
epeat
epe
at Ablation
Abla
A ation
n=6
Yes
Acut
Acu
Acute
e Succes
Su
Success
ccess
cces
s
n=6
6
Repeat EPS, n=1
Repeat EPS,
n=6
No VT inducible,
n=1
ICD implanted,
n=3
ICD
CD impl
implante
implanted,
anted,
ante
d,
n=7
Repeat Ablation
o
on
n=1*
No ICD, n=1
Positive EPS
n=5
ICD implanted,
n=5
VT Inducible,
V
n=
n=2
n
Ac
Acute
c
Success
n=
n=2
Repeat EPS,
n=2
Negative EPS
n=1
Positive EPS
n=1
No ICD , n=1
ICD implanted,
n=1
Negative EPS
n=1
No ICD ,n=1
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A Stepwise Approach to the Management of Post-Infarct Ventricular Tachycardia Using
Catheter Ablation as the First Line Treatment: A Single Center Experience
Maheshwar Pauriah, Gabriel Cismaru, Isabelle Magnin-Poull, Marius Andronache, Jean-Marc Sellal,
Jérôme Schwartz, Béatrice Brembilla-Perrot, Nicolas Sadoul, Etienne Aliot and Christian de Chillou
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Circ Arrhythm Electrophysiol. published online March 19, 2013;
Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue,
Dallas, TX 75231
Copyright © 2013 American Heart Association, Inc. All rights reserved.
Print ISSN: 1941-3149. Online ISSN: 1941-3084
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circep.ahajournals.org/content/early/2013/03/19/CIRCEP.113.000261
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