Ischemic or Coronary Evaluations in Patients With Monomorphic VT Electrical Storm Undergoing VT Ablation

Effect of Ischemia Testing and Coronary Revascularization on Mortality and Ventricular Tachycardia Recurrence in Patients With Monomorphic Ventricular Tachycardia Without Acute Coronary Syndrome: A Meta-Analysis and Systematic Review

BACKGROUND

Studies show mixed results regarding the effect of coronary revascularization on mortality benefit and ventricular tachycardia (VT) recurrence in patients with monomorphic VT without acute coronary syndrome (ACS). This meta-analysis aimed to assess the effect of ischemia testing and/or coronary revascularization on mortality and VT recurrence in a pooled data set.

METHODS

Databases including PubMed, Google Scholar, and the Cochrane Library were searched from January 2000 to December 2023 for studies reporting event data on mortality and VT recurrence in patients without ACS who presented with monomorphic VT. Data were pooled and analyzed using random effects meta-analysis.

RESULTS

The pooled sample consisted of a total of five studies, with 1062 patients, of whom 433 underwent ischemia testing and/or coronary revascularization and 629 did not. There was no statistically significant difference in the mortality and VT recurrence in the patients who underwent ischemia testing and/or revascularization versus those who did not (mortality odds ratio [OR]: 0.98; [95% confidence interval (CI): 0.62 to 1.53]; p = 0.92; VT recurrence OR: 1.07; [95% CI: 0.51 to 2.26]; p = 0.86). No publication bias was detected by examination of the funnel plot, Begg-Mazumdar's test (p = 0.80), and Egger's test (p = 0.91).

CONCLUSION

In conclusion, in patients with sustained monomorphic VT in the absence of ACS, ischemia testing and/or revascularization does not lead to improved mortality or a decrease in the incidence of VT recurrence.

Yield of Coronary Assessment in Sustained Monomorphic Ventricular Tachycardia

BACKGROUND

Coronary assessment is frequently conducted in patients with sustained monomorphic ventricular tachycardia (SMVT); however, its yield and subsequent treatment implications remain unclear. This study aimed to determine the prevalence of coronary artery disease (CAD) in patients presenting with SMVT, factors influencing clinician referral for coronary assessment, and clinical outcomes based on revascularisation or medical management of CAD.

METHOD

Consecutive patients presenting with acute SMVT requiring inpatient admission between 2017 and 2022 were identified.

RESULTS

A total of 249 individual patients with SMVT were identified, with 140 undergoing coronary assessment. Referral for coronary assessment was driven by chest pain (p<0.001) and increased troponin kinetics (p<0.001). No patient with SMVT had an acute coronary occlusion. Significant CAD was found in 48 (34%) patients, and traditional ischaemic features did not predict significant CAD. Nineteen (40%) patients with significant CAD underwent revascularisation (n=15 percutaneous coronary intervention, n=4 coronary artery bypass grafting). There was no significant difference in time to ventricular tachycardia (VT) recurrence between revascularised and medically managed CAD (hazard ratio 1.670; 95% confidence interval 0.756-3.687; p=0.199). A total of five of six patients who underwent a revascularisation-only strategy (no upfront antiarrhythmic therapy or ablation) had VT recurrence (median time to recurrence 8.9 months).

CONCLUSIONS

Despite being frequently performed, coronary assessment in SMVT has only modest yield, with no patients having an acute coronary occlusion. Traditional clinical factors of ischaemia did not improve this yield. Revascularisation alone did not improve freedom from VT.

Competing risks of monomorphic vs. non-monomorphic ventricular arrhythmias in primary prevention implantable cardioverter-defibrillator recipients: Global Electrical Heterogeneity and Clinical Outcomes (GEHCO) study

AIMS

Ablation of monomorphic ventricular tachycardia (MMVT) has been shown to reduce shock frequency and improve survival. We aimed to compare cause-specific risk factors for MMVT and polymorphic ventricular tachycardia (PVT)/ventricular fibrillation (VF) and to develop predictive models.

METHODS AND RESULTS

The multicentre retrospective cohort study included 2668 patients (age 63.1 ± 13.0 years; 23% female; 78% white; 43% non-ischaemic cardiomyopathy; left ventricular ejection fraction 28.2 ± 11.1%). Cox models were adjusted for demographic characteristics, heart failure severity and treatment, device programming, and electrocardiogram metrics. Global electrical heterogeneity was measured by spatial QRS-T angle (QRSTa), spatial ventricular gradient elevation (SVGel), azimuth, magnitude (SVGmag), and sum absolute QRST integral (SAIQRST). We compared the out-of-sample performance of the lasso and elastic net for Cox proportional hazards and the Fine-Gray competing risk model. During a median follow-up of 4 years, 359 patients experienced their first sustained MMVT with appropriate implantable cardioverter-defibrillator (ICD) therapy, and 129 patients had their first PVT/VF with appropriate ICD shock. The risk of MMVT was associated with wider QRSTa [hazard ratio (HR) 1.16; 95% confidence interval (CI) 1.01-1.34], larger SVGel (HR 1.17; 95% CI 1.05-1.30), and smaller SVGmag (HR 0.74; 95% CI 0.63-0.86) and SAIQRST (HR 0.84; 95% CI 0.71-0.99). The best-performing 3-year competing risk Fine-Gray model for MMVT [time-dependent area under the receiver operating characteristic curve (ROC(t)AUC) 0.728; 95% CI 0.668-0.788] identified high-risk (> 50%) patients with 75% sensitivity and 65% specificity, and PVT/VF prediction model had ROC(t)AUC 0.915 (95% CI 0.868-0.962), both satisfactory calibration.

CONCLUSION

We developed and validated models to predict the competing risks of MMVT or PVT/VF that could inform procedural planning and future randomized controlled trials of prophylactic ventricular tachycardia ablation.

CLINICAL TRIAL REGISTRATION

URL:www.clinicaltrials.gov Unique identifier:NCT03210883.

Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society

Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.

Ischemia testing and revascularization in patients with monomorphic ventricular tachycardia: A relic of the past?

Testing for myocardial ischemia in patients presenting with sustained monomorphic Ventricular Tachycardia(VT) even without evidence of acute myocardial infarction is a tempting strategy that is frequently utilized in clinical practice. Monomorphic VT is mainly caused by re-entry around chronic myocardial scar and active ischemia has no role in its pathogenesis, thus making testing for ischemia futile, at least in theory. This systematic literature review sought to address the usefulness of ischemia testing (mainly coronary angiography) in patients presenting with monomorphic VT through 8 selected studies after evaluating a total of 130 published manuscripts. Particularly, we sought to unveil whether coronary angiography and possibly concomitant revascularization leads to lesser tachycardia recurrence. Our conclusion can be summarized as follows: this approach whether combined with revascularization or not, does not seem to reduce VT recurrence nor does it affect mortality in such patients. Even though most of the published literature points at this direction, validation from randomized controlled trials is imperative.