Vasovagal Responses to Human Monomorphic Ventricular Tachycardia: Hemodynamic Implications From Sinus Rate Analysis

[Role of ventricular tachycardia ablation in patients with systolic heart failure]

Patients with systolic heart failure (HF) and structural heart disease often suffer from ventricular tachycardias (VTs), which lead to increased morbidity and mortality. Despite advancements in pharmacological therapy and the use of implantable cardioverter-defibrillators, treatment options are limited due to side effects and decreased effectiveness. Catheter ablation (CA) has emerged as a promising therapy for drug-refractory VTs, especially in patients with structural heart disease. This article reviews current knowledge on the indications, efficacy, and long-term prognosis of CA in patients with HF. Additionally, it discusses the importance of preprocedural planning, risk stratification, and emerging therapeutic strategies such as mechanical circulatory support and stereotactic arrhythmia radioablation. The complex relationship between VT and HF, as well as potential risks like acute hemodynamic decompensation, are also addressed.

Therapeutic potential of conduction system pacing as a method for improving cardiac output during ventricular tachycardia

BACKGROUND

Ventricular tachycardia (VT) reduces cardiac output through high heart rates, loss of atrioventricular synchrony, and loss of ventricular synchrony. We studied the contribution of each mechanism and explored the potential therapeutic utility of His bundle pacing to improve cardiac output during VT.

METHODS

Study 1 aimed to improve the understanding of mechanisms of harm during VT (using pacing simulated VT). In 23 patients with left ventricular impairment, we recorded continuous ECG and beat-by-beat blood pressure measurements. We assessed the hemodynamic impact of heart rate and restoration of atrial and biventricular synchrony. Study 2 investigated novel pacing interventions during clinical VT by evaluating the hemodynamic effects of His bundle pacing at 5 bpm above the VT rate in 10 patients.

RESULTS

In Study 1, at progressively higher rates of simulated VT, systolic blood pressure declined: at rates of 125, 160, and 190 bpm, -22.2%, -42.0%, and -58.7%, respectively (ANOVA p < 0.0001). Restoring atrial synchrony alone had only a modest beneficial effect on systolic blood pressure (+ 3.6% at 160 bpm, p = 0.2117), restoring biventricular synchrony alone had a greater effect (+ 9.1% at 160 bpm, p = 0.242), and simultaneously restoring both significantly increased systolic blood pressure (+ 31.6% at 160 bpm, p = 0.0003). In Study 2, the mean rate of clinical VT was 143 ± 21 bpm. His bundle pacing increased systolic blood pressure by + 14.2% (p = 0.0023). In 6 of 10 patients, VT terminated with His bundle pacing.

CONCLUSIONS

Restoring atrial and biventricular synchrony improved hemodynamic function in simulated and clinical VT. Conduction system pacing could improve VT tolerability and treatment.

Editor-in-Chief's Top Picks From 2023

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16M+), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (Original Investigations, Review Articles, Society Documents, and the Global Burden of Diseases) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations∗ and podcasts. The highlights comprise the following sections: Aorta; Basic and Translational Science; Cardiac Failure, Myocarditis, and Pericarditis; Cardiomyopathies and Genetics; Congenital Heart Disease; Coronary, Peripheral, and Structural Interventions; Coronavirus; Health Promotion and Preventive Cardiology; Imaging; Metabolic and Lipid Disorders; Neurovascular Disease and Dementia; Rhythm Disorders and Thromboembolism; and Valvular Heart Disease.1-104 ∗ To view the full manuscript, including the full-sized Central Illustration, please refer to the original publication in JACC.