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Gupte T, Liang JJ, Latchamsetty R, Crawford T, Jongnarangsin K, Bogun F, Ghannam M. Long-term outcomes of patients with ventricular arrhythmias and negative programmed ventricular stimulation followed with implantable loop recorders: Impact of delayed-enhancement cardiac magnetic resonance imaging. J Cardiovasc Electrophysiol 2023; 34:2581-2589. [PMID: 37921260 DOI: 10.1111/jce.16109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Programed ventricular stimulation (PVS) is a risk stratification tool in patients at risk for adverse arrhythmia outcomes. Patients with negative PVS may yet be at risk for adverse arrhythmia-related events, particularly in the presence of symptomatic ventricular arrhythmias (VA). OBJECTIVE To investigate the long-term outcomes of real-world patients with symptomatic VA without indication for device therapy and negative PVS, and to examine the role of cardiac scaring on arrhythmia recurrence. METHODS Patients with symptomatic VA, and late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR), and negative PVS testing were included. All patients underwent placement of implantable cardiac monitors (ICM). Survival analysis was performed to investigate the impact of LGE-CMR findings on survival free from adverse arrhythmic events. RESULTS Seventy-eight patients were included (age 60 ± 14 years, women n = 36 (46%), ejection fraction 57 ± 9%, cardiomyopathy n = 26 (33%), mitral valve prolapse [MVP] n = 9 (12%), positive LGE-CMR scar n = 49 (62%), history of syncope n = 23 (29%)) including patients with primarily premature ventricular contractions (n = 21) or nonsustained VA (n = 57). Patients were followed for 1.6 ± 1.5 years during which 14 patients (18%) experienced VA requiring treatment (n = 14) or syncope due to bradycardia (n = 2). Four/9 patients (44%) with MVP experienced VA (n = 3) or syncope (n = 1). Baseline characteristics between those with and without adverse events were similar (p > 0.05); however, the presence of cardiac scar on LGE-CMR was independently associated with an increased risk of adverse events (hazard ratio: 5.6 95% confidence interval: [1.2-27], p = 0.03, log-rank p = 0.03). CONCLUSIONS In a real-world cohort with long-term follow-up, adverse arrhythmic outcomes occurred in 18% of patients with symptomatic VA despite negative PVS, and this risk was significantly greater in patients with positive DE-CMR scar. Long term-monitoring, including the use of ICM, may be appropriate in these patients.
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Affiliation(s)
- Trisha Gupte
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jackson J Liang
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rakesh Latchamsetty
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas Crawford
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Krit Jongnarangsin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Ghannam
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Shinoda Y, Komatsu Y, Nogami A, Igarashi M, Yamasaki H, Sekiguchi Y, Aonuma K, Ieda M. Stepwise approach to induce infrequent premature ventricular complex using bolus isoproterenol and epinephrine infusion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:437-443. [PMID: 32115739 DOI: 10.1111/pace.13893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/01/2019] [Accepted: 12/10/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Paucity of a premature ventricular complex (PVC) during ablation procedures may occur and be associated with a lower success rate. Isoproterenol (ISP) injections are commonly used to induce PVC; however, the induced tachycardia sometimes prevents the appearance of PVC. Epinephrine (EPI) administration may be an alternative strategy to induce PVC due to its smaller effect on heart rate (HR). This study sought to examine the electrophysiological impact of EPI injection, with a stepwise induction protocol, for infrequent intraprocedural PVC. METHODS We studied 78 consecutive patients who underwent catheter ablation of idiopathic frequent PVC. If no PVC was observed at the beginning of the procedure, ISP (10 µg) was injected. If clinical PVC was not induced by ISP administration, EPI (10 µg) was injected. RESULTS Of 18 patients without PVC at baseline, ISP injection induced PVC in five patients. Of the remaining 13 patients, EPI injection successfully induced PVC in seven patients (53%). The maximum HR and increments of HR after EPI injection were significantly lower than those after ISP injection (99 ± 15 vs 137 ± 15 bpm, P = .001; 22 ± 10 vs 53 ± 12 bpm, P < .001, respectively). There were no complications related to the induction protocol. CONCLUSION EPI injection following ISP injection is an effective and safe stepwise approach for the induction of infrequent PVC in the electrophysiology laboratory. It is hypothesized that α- and β-adrenergic receptor stimulation by EPI injections, with reduced HR acceleration compared to that with ISP injections, may result in the successful induction of PVC.
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Affiliation(s)
- Yasutoshi Shinoda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuki Komatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Miyako Igarashi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Killu AM, Mulpuru SK, Asirvatham SJ. Mapping and ablation procedures for the treatment of ventricular tachycardia. Expert Rev Cardiovasc Ther 2016; 14:1071-87. [PMID: 27269734 DOI: 10.1080/14779072.2016.1186541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Ventricular tachycardia (VT) may occur in the presence or absence of structural heart disease. Given that the management of VT hinges on the presence of symptoms and risk of sudden cardiac death (SCD), the main treatment goals are elimination of symptoms (including frequent implantable cardioverter defibrillator [ICD] therapies) and prevention of SCD. Unfortunately, medical management is suboptimal in a significant proportion of patients. As such, ablative therapy plays a prominent role in the treatment of ventricular tachycardia. AREAS COVERED In this review, we will discuss various VT disorders that are encountered in patients with and without structural heart disease. Further, we will highlight salient features regarding mapping and ablation of the various VT syndromes. Finally, we will discuss what lies on the horizon for VT ablation. Expert commentary: Meticulous mapping should aim to find the region that is most likely to be successful and least likely to result in a complication. Although recognition of the various mechanisms of VT, familiarity with different methods to mapping and ablation, and awareness of potential limitations of current approaches is critical, a thorough understanding of the fundamental principles and nuances of each facet within EP is required to ensure optimal outcomes for our patients.
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Affiliation(s)
- Ammar M Killu
- a Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA.,b Department of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA
| | - Siva K Mulpuru
- a Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA.,b Department of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA
| | - Samuel J Asirvatham
- a Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA.,b Department of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA.,c Department of Pediatrics and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
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Kumar N, Aksoy I, Phan K, Vainer J, Timmermans C. Coronary spasm during cardiac electrophysiological study following isoproterenol infusion. Interv Med Appl Sci 2014; 6:183-6. [PMID: 25598993 DOI: 10.1556/imas.6.2014.4.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/14/2014] [Accepted: 09/15/2014] [Indexed: 11/19/2022] Open
Abstract
Sudden cardiac death (SCD) remains the leading cause of death in industrialized world. The majority of SCD is caused by ventricular fibrillation associated with structural and/or ischemic heart disease. Ventricular fibrillation represents the final common pathway for SCD and, thus, is an attractive target for ablation. According to class I recommendation level of evidence A, an implantable cardioverter defibrillator (ICD) should be implanted for such patients [1]. Other than programmed electrical extrastimulus technique, isoproterenol infusion is commonly used in invasive cardiac electrophysiology labs for arrhythmia induction. We hereby report a rare case of transient coronary spasm during isoproterenol infusion for ventricular tachycardia induction testing.
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Brembilla-Perrot B, Muhanna I, Marçon O, Popovic B, Terrier de la Chaise A, Louis P, Andronache M, Nippert M, Claudon O, Beurrier D, Houriez P, Belhakem H. Increased sensitivity of electrophysiological study by isoproterenol infusion in unexplained syncope. Int J Cardiol 2006; 106:82-7. [PMID: 16321671 DOI: 10.1016/j.ijcard.2004.12.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Accepted: 12/31/2004] [Indexed: 11/23/2022]
Abstract
UNLABELLED The purpose of the study was to evaluate the interests of electrophysiologic study (EPS) after infusion of isoproterenol in patients with syncope and negative EPS in control state. METHODS 1350 patients were consecutively admitted for syncope and EPS. Patients were included if they had no history of tachycardia, a normal Holter monitoring, a negative EPS in control state. EPS was repeated after infusion of 2-4 mug/kg of isoproterenol. RESULTS 256 patients, 35 with exercise-related syncope and 105 with heart disease (HD), were recruited. After isoproterenol, an arrhythmia was identified as the sign associated with syncope in 102 patients (40%): SVT in 32 patients, VT in 36 patients, infrahisian 2nd or 3rd degree AV block in three patients and vasovagal reaction in 31 patients. Arrhythmias were more frequent in patients with HD (50/105) than in those without HD (52/151) (p<0.05); SVT tended to be more frequent in patients without HD (n=23) than in those with HD (n=9) (p<0.1); VT was more frequent in patients with HD (n=26) than in those without HD (n=10) (p<0.001). There was no relationship between a positive isoproterenol testing and occurrence of syncope at exercise (19/35 vs 81/221) (p<0.1). CONCLUSION isoproterenol infusion increased the sensitivity of EPS in patients with syncope, related or not to exercise, and with negative study in control state, but principally in those with HD. However, SVT was diagnosed in patients without HD and EPS associated with isoproterenol infusion remained an important and rapid tool to establish this diagnosis.
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Delle Karth G, Reinelt P, Buberl A, Geppert A, Huelsmann M, Berger R, Heinz G. Circadian variation in ventricular tachycardia and atrial fibrillation in a medical-cardiological ICU. Intensive Care Med 2003; 29:963-968. [PMID: 12698245 DOI: 10.1007/s00134-003-1735-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2002] [Accepted: 02/28/2003] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the diurnal distribution of ventricular tachycardia (VT) and atrial fibrillation (AF) in critically ill patients. DESIGN AND SETTING Prospective observational study (episode-based design) in an eight-bed medical/cardiological ICU at a university hospital that also admits postoperative patients. PATIENTS 98 consecutive patients with AF ( n=55) or ventricular tachycardia ( n=43). MEASUREMENTS AND RESULTS There were a total of 218 arrhythmia episodes (83 AF, 136 VT). The time of arrhythmia onset was not evenly distributed. Circadian variation in VT but not AF onset was well represented by a sine wave function. Both VT and AF fibrillation showed a trough during the night. The distribution of VT and AF episodes did not differ significantly with or without analgosedation. CONCLUSIONS In critically ill patients the onset of VT and AF over 24-h is nonuniformly distributed. In VT this circadian pattern of occurrence is well modeled by a sine wave function peaking between noon and 2 p.m. The circadian pattern is less clear for AF. The circadian variation is seen irrespective of the presence of absence of analgosedation for both arrhythmias.
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Affiliation(s)
- Georg Delle Karth
- Department of Cardiology, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Peter Reinelt
- Department of Cardiology, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Anton Buberl
- Department of Cardiology, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Alexander Geppert
- Department of Cardiology, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Martin Huelsmann
- Department of Cardiology, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Rudolf Berger
- Department of Cardiology, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gottfried Heinz
- Department of Cardiology, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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