1
|
Gurin MI, Xia Y, Tarabanis C, Goldberg RI, Knotts RJ, Donnino R, Reyentovich A, Bernstein S, Jankelson L, Kushnir A, Holmes D, Spinelli M, Park DS, Barbhaiya CR, Chinitz LA, Aizer A. Catheter ablation compared to medical therapy for ventricular tachycardia in sarcoidosis: nationwide outcomes and hospital readmissions. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 44:100421. [PMID: 39070127 PMCID: PMC11279686 DOI: 10.1016/j.ahjo.2024.100421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/30/2024]
Abstract
Background Catheter ablation (CA) for ventricular tachycardia (VT) can be a useful treatment strategy, however, few studies have compared CA to medical therapy (MT) in the sarcoidosis population. Objective To assess in-hospital outcomes and unplanned readmissions following CA for VT compared to MT in patients with sarcoidosis. Methods Data was obtained from the Nationwide Readmissions Database between 2010 and 2019 to identify patients with sarcoidosis admitted for VT either undergoing CA or MT during elective and non-elective admission. Primary endpoints were a composite endpoint of inpatient mortality, cardiogenic shock, cardiac arrest and 30-day hospital readmissions. Procedural complications at index admission and causes of readmission were also identified. Results Among 1581 patients, 1217 with sarcoidosis and VT underwent MT compared to 168 with CA during non-elective admission. 63 patients admitted electively underwent CA compared with 129 managed medically. There was no difference in the composite outcome for patients undergoing catheter ablation or medical therapy during both non-elective (9.0 % vs 12.0 %, p = 0.312) and elective admission (3.2 % vs. 7.8 %, p = 0.343). The most common cause of readmission were ventricular arrhythmias (VA) in both groups, however, those undergoing elective CA were less likely to be readmitted for VA compared to non-elective CA. The most common complication in the CA group was cardiac tamponade (4.8 %). Conclusion VT ablation is associated with similar rates of 30-day readmission compared to MT and does not confer increased risk of harm with respect to inpatient mortality, cardiogenic shock or cardiac arrest. Further research is warranted to determine if a subgroup of sarcoidosis patients admitted with VT are better served with an initial conservative management strategy followed by VT ablation.
Collapse
Affiliation(s)
- Michael I. Gurin
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Yuhe Xia
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Constantine Tarabanis
- Department of Medicine, NYU Langone Health, New York University School of Medicine, New York, NY, United States of America
| | - Randal I. Goldberg
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Robert J. Knotts
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Robert Donnino
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Alex Reyentovich
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Scott Bernstein
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Lior Jankelson
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Alexander Kushnir
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Douglas Holmes
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Michael Spinelli
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - David S. Park
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Chirag R. Barbhaiya
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Larry A. Chinitz
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| |
Collapse
|
2
|
Kim D, Collins JD, White JA, Hanneman K, Lee DC, Patel AR, Hu P, Litt H, Weinsaft JW, Davids R, Mukai K, Ng MY, Luetkens JA, Roguin A, Rochitte CE, Woodard PK, Manisty C, Zareba KM, Mont L, Bogun F, Ennis DB, Nazarian S, Webster G, Stojanovska J. SCMR expert consensus statement for cardiovascular magnetic resonance of patients with a cardiac implantable electronic device. J Cardiovasc Magn Reson 2024; 26:100995. [PMID: 38219955 PMCID: PMC11211236 DOI: 10.1016/j.jocmr.2024.100995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024] Open
Abstract
Cardiovascular magnetic resonance (CMR) is a proven imaging modality for informing diagnosis and prognosis, guiding therapeutic decisions, and risk stratifying surgical intervention. Patients with a cardiac implantable electronic device (CIED) would be expected to derive particular benefit from CMR given high prevalence of cardiomyopathy and arrhythmia. While several guidelines have been published over the last 16 years, it is important to recognize that both the CIED and CMR technologies, as well as our knowledge in MR safety, have evolved rapidly during that period. Given increasing utilization of CIED over the past decades, there is an unmet need to establish a consensus statement that integrates latest evidence concerning MR safety and CIED and CMR technologies. While experienced centers currently perform CMR in CIED patients, broad availability of CMR in this population is lacking, partially due to limited availability of resources for programming devices and appropriate monitoring, but also related to knowledge gaps regarding the risk-benefit ratio of CMR in this growing population. To address the knowledge gaps, this SCMR Expert Consensus Statement integrates consensus guidelines, primary data, and opinions from experts across disparate fields towards the shared goal of informing evidenced-based decision-making regarding the risk-benefit ratio of CMR for patients with CIEDs.
Collapse
Affiliation(s)
- Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | - James A White
- Departments of Cardiac Sciences and Diagnostic Imaging, Cummings School of Medicine, University of Calgary, Calgary, Canada
| | - Kate Hanneman
- Department of Medical Imaging, University Medical Imaging Toronto, Toronto General Hospital and Peter Munk Cardiac Centre, University of Toronto, Toronto, Canada
| | - Daniel C Lee
- Department of Medicine (Division of Cardiology), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amit R Patel
- Cardiovascular Division, University of Virginia, Charlottesville, VA, USA
| | - Peng Hu
- School of Biomedical Engineering, ShanghaiTech University, Shanghai, China
| | - Harold Litt
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan W Weinsaft
- Department of Medicine (Division of Cardiology), Weill Cornell Medicine, New York, NY, USA
| | - Rachel Davids
- SHS AM NAM USA DI MR COLLAB ADV-APPS, Siemens Medical Solutions USA, Inc., Chicago, Il, USA
| | - Kanae Mukai
- Salinas Valley Memorial Healthcare System, Ryan Ranch Center for Advanced Diagnostic Imaging, Monterey, CA, USA
| | - Ming-Yen Ng
- Department of Diagnostic Radiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, the Hong Kong Special Administrative Region of China
| | - Julian A Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Ariel Roguin
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera and Faculty of Medicine. Technion - Israel Institute of Technology, Israel
| | - Carlos E Rochitte
- Heart Institute, InCor, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK
| | - Karolina M Zareba
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Lluis Mont
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Daniel B Ennis
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory Webster
- Department of Pediatrics (Cardiology), Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Jadranka Stojanovska
- Department of Radiology, Grossman School of Medicine, New York University, New York, NY, USA
| |
Collapse
|
3
|
Subramanian M, Atreya AR, Saggu DK, Yalagudri S, Calambur N. Catheter ablation of ventricular tachycardia: strategies to improve outcomes. Front Cardiovasc Med 2023; 10:966634. [PMID: 37645526 PMCID: PMC10461400 DOI: 10.3389/fcvm.2023.966634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
Catheter ablation of ventricular arrhythmias has evolved considerably since it was first described more than 3 decades ago. Advancements in understanding the underlying substrate, utilizing pre-procedural imaging, and evolving ablation techniques have improved the outcomes of catheter ablation. Ensuring safety and efficacy during catheter ablation requires adequate planning, including analysis of the 12 lead ECG and appropriate pre-procedural imaging. Defining the underlying arrhythmogenic substrate and disease eitology allow for the developed of tailored ablation strategies, especially for patients with non-ischemic cardiomyopathies. During ablation, the type of anesthesia can affect VT induction, the quality of the electro-anatomic map, and the stability of the catheter during ablation. For high risk patients, appropriate selection of hemodynamic support can increase the success of VT ablation. For patients in whom VT is hemodynamically unstable or difficult to induce, substrate modification strategies can aid in safe and successful ablation. Recently, there has been an several advancements in substrate mapping strategies that can be used to identify and differentiate local late potentials. The incorporation of high-definition mapping and contact-sense technologies have both had incremental benefits on the success of ablation procedures. It is crucial to harness newer technology and ablation strategies with the highest level of peri-procedural safety to achieve optimal long-term outcomes in patients undergoing VT ablation.
Collapse
Affiliation(s)
- Muthiah Subramanian
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Auras R. Atreya
- Department of Cardiology, University of Arkansas Medical Sciences, Little Rock, AR, United States
| | - Daljeet Kaur Saggu
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Sachin Yalagudri
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Narasimhan Calambur
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| |
Collapse
|
4
|
Chung WH, Hayase J, Do DH, Dixit N, Ajijola O, Buch E, Boyle N, Shivkumar K, Bradfield JS. Clinical predictors and implications of cardiac inflammation detected on positron emission tomography (PET) in patients referred for premature ventricular complex (PVC) ablation. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01446-z. [PMID: 36510109 DOI: 10.1007/s10840-022-01446-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Positron emission tomography computed tomography (PET-CT) is not routinely used for premature ventricular complexes (PVCs). Whether specific clinical factors are associated with abnormal PET-CT results is not clear. METHODS The treatment courses and baseline characteristics of consecutive patients in a single center between 2012 and 2021, age > 18 years old, and who received 18F-fluorodeoxyglucose (FDG) PET-CT imaging for evaluation of PVCs were retrospectively analyzed. RESULTS A total of 102 patients was included. Of these, 27 patients (26.4%) had abnormal PET-CT and 61 (59.8%) had normal imaging. Abnormal PET-CT findings were associated with non-sustained ventricular tachycardia (NSVT) (95.2% vs. 52.6%, p = 0.001), higher number of PVC morphologies (2.29 ± 0.7 vs. 1.31 ± 0.6, p < 0.001), greater PVC coupling interval dispersion (72.47 ± 66.4 ms vs. 13.42 ± 17.9 ms, p < 0.001), and greater likelihood of fast heart rate dependent PVCs (78.5% vs. 38.2%, p = 0.017). Fourteen (51.8%) patients had an abnormal PET-CT and abnormal late gadolinium enhancement (LGE). Patients with abnormal PET-CT were more frequently treated with immunosuppression (81.4% vs. 3.2%, p < .0001) than with catheter ablation (11.1% vs. 45.9%, p = 0.002) compared to the normal PET-CT group. Over a median follow-up of 862 days (IQR 134, 1407), PVC burden decreased in both groups [from 23 ± 16% to 9 ± 10% (p < 0.001) in abnormal PET-CT group and from 21 ± 15% to 7 ± 10% (p < 0.001) in normal PET-CT group]. CONCLUSIONS Abnormal PET-CT findings were more commonly associated with NSVT, multiform PVCs, greater PVC coupling interval dispersion, and fast heart rate dependent PVCs. LGE was not sensitive for detecting inflammation. Immunosuppression was effective in managing PVCs with abnormal PET-CT.
Collapse
Affiliation(s)
- Wei-Hsin Chung
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA.
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung, Taiwan.
| | - Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Duc H Do
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Neal Dixit
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Olujimi Ajijola
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Eric Buch
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Noel Boyle
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| |
Collapse
|
5
|
Maher T, Clarke JR, Virk Z, d'Avila A. Patient Selection, Techniques, and Complication Mitigation for Epicardial Ventricular Tachycardia Ablation. Card Electrophysiol Clin 2022; 14:657-677. [PMID: 36396183 DOI: 10.1016/j.ccep.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Percutaneous epicardial ventricular tachycardia ablation can decrease implanted cardioverter defibrillator shocks and hospitalizations; proper patient selection and procedural technique are imperative to maximize the benefit-risk ratio. The best candidates for epicardial ventricular tachycardia will depend on history of prior ablation, type of cardiomyopathy, and specific electrocardiogram and cardiac imaging findings. Complications include hemopericardium, hemoperitoneum, coronary vessel injury, and phrenic nerve injury. Modern epicardial mapping techniques provide new understandings of the 3-dimensional nature of reentrant ventricular tachycardia circuits across cardiomyopathy etiologies. Where epicardial access is not feasible, alternative techniques to reach epicardial ventricular tachycardia sources may be necessary.
Collapse
Affiliation(s)
- Timothy Maher
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - John-Ross Clarke
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Zain Virk
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Andre d'Avila
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
6
|
Tan JL, Jin C, Lee JZ, Gaughan J, Iwai S, Russo AM. Outcomes of catheter ablation for ventricular tachycardia in patients with sarcoidosis: Insights from the National Inpatient Sample database (2002-2018). J Cardiovasc Electrophysiol 2022; 33:2585-2598. [PMID: 36335632 PMCID: PMC10098605 DOI: 10.1111/jce.15708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/05/2022] [Accepted: 10/02/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Data on utilization, major complications, and in-hospital mortality of catheter ablation (CA) for sarcoidosis-related ventricular tachycardia (VT) are limited. We sought to determine the outcomes of sarcoidosis-related VT, and incidence and predictors of complications associated with the CA procedure. METHODS We queried the 2002-2018 National Inpatient Sample database to identify patients aged ≥18 years with sarcoidosis admitted with VT. A 1:3 propensity score-matched (PSM) analysis was used to compare patient outcomes between CA and medically managed groups. Multivariable regression was performed to determine independent predictors of in-hospital mortality and procedural complications associated with the CA procedure. RESULTS Of 3220 sarcoidosis patients with VT, 132 (4.1%) underwent CA. Patients who underwent CA were younger, male predominant, more likely Caucasian, had differences in baseline comorbidities including more likely to have heart failure, less likely to have prior myocardial infarction, COPD, or severe renal disease, had a higher mean household income, and more likely admitted to a larger/urban teaching hospital. After PSM, we examined 106 CA cases and 318 medically managed cases. There was a trend toward a lower in-hospital mortality rate in the CA group when compared to the medically managed group (1.9% vs. 6.6%, p = 0.08). The most common complications were pericardial drainage (5.3%), postoperative hemorrhage (3.8%), accidental puncture periprocedure (3.0%), and cardiac tamponade (2.3%). Independent predictors of in-hospital mortality and procedural complications among the CA group included congestive heart failure (odds ratio [OR], 13.2; 95% confidence interval [CI], 1.7-104.2) and mild to moderate renal disease (OR, 3.9; 95% CI, 1.1-13.3). CONCLUSIONS Compared to patients with sarcoidosis-related VT who received medical therapy alone, those who underwent CA have a trend for a lower mortality rate despite procedure-related complications occurring as high as 9.1%. Additional studies are recommended to better evaluate the benefits and risks of VT ablation in this group.
Collapse
Affiliation(s)
- Jian Liang Tan
- Division of Cardiovascular Disease, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Chengyue Jin
- Department of Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Justin Z Lee
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - John Gaughan
- Cooper Research Institute, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Sei Iwai
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Andrea M Russo
- Division of Cardiovascular Disease, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| |
Collapse
|
7
|
Detection of inflammation using cardiac positron emission tomography for evaluation of ventricular arrhythmias: An institutional experience. Heart Rhythm 2022; 19:2064-2072. [PMID: 35932988 DOI: 10.1016/j.hrthm.2022.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of cardiac positron emission tomography-computed tomography (PET-CT) is increasingly used for the detection of underlying inflammation in patients with ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]), but the role of PET-CT remains undefined, particularly for patients who do not meet Task Force criteria for sarcoidosis. OBJECTIVE The purpose of this study was to determine the utility of PET-CT for clinical evaluation of VT/VF in patients with nonischemic cardiomyopathy. METHODS Consecutive patients with nonischemic cardiomyopathy and VT/VF who underwent cardiac PET-CT to detect inflammation between 2012 and 2019 were analyzed for baseline demographic characteristics, imaging results, and outcomes. Patients with known sarcoidosis or other conditions requiring immunosuppressive therapy were excluded. RESULTS PET-CT was performed in 133 patients with mean age 56.3 ± 13.5 years and left ventricular ejection fraction 43% ± 16.1%, with evidence of myocardial inflammation detected in 32 (23.5%). Patients with myocardial inflammation were managed conservatively with medical therapy including immunosuppressive agents. Ten patients with myocardial inflammation ultimately required catheter ablation for ongoing arrhythmias. There was no significant difference in arrhythmia recurrence between PET-positive and PET-negative groups (37.5% vs 32.4%; P = .43) or in time to recurrence (P = .26), in spite of the disparate management strategies. Gadolinium-enhanced cardiac magnetic resonance imaging was performed in 96 patients (72%); however, magnetic resonance imaging did not detect 31% of cases with active inflammation that were otherwise detected on PET-CT. CONCLUSION The use of PET-CT significantly improves the detection of underlying myocardial inflammation contributing to ventricular arrhythmias. Management of these patients with immunosuppressive medical therapy is effective for arrhythmia control and may obviate the need for invasive ablation procedures in some patients.
Collapse
|
8
|
Ghannam M, Bogun F. Improving Outcomes in Ventricular Tachycardia Ablation Using Imaging to Identify Arrhythmic Substrates. Card Electrophysiol Clin 2022; 14:609-620. [PMID: 36396180 DOI: 10.1016/j.ccep.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Ventricular tachycardia (VT) ablation is limited by modest acute and long-term success rates, in part due to the challenges in accurately identifying the arrhythmogenic substrate. The combination of multimodality imaging along with information from electroanatomic mapping allows for a more comprehensive assessment of the arrhythmogenic substrate which facilitates VT ablation, and the use of preprocedural imaging has been shown to improve long-term ablation outcomes. Beyond regional recognition of the arrhythmogenic substrate, advanced imaging techniques can be used to create tailored ablation strategies preprocedurally. This review will focus on how imaging can be used to guide ablation planning and execution with a focus on clinical applications aimed at improving the outcome of VT ablation procedures.
Collapse
Affiliation(s)
- Michael Ghannam
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA.
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA
| |
Collapse
|
9
|
Slivnick JA, Wali E, Patel AR. Imaging in Cardiac Sarcoidosis: Complementary Role of Cardiac Magnetic Resonance and Cardiac Positron Emission Tomography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2022. [DOI: 10.1007/s12410-022-09571-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Evaluation and Catheter Ablation of Ventricular Arrhythmias in Cardiac Sarcoidosis. J Clin Med 2022; 11:jcm11226718. [PMID: 36431195 PMCID: PMC9694385 DOI: 10.3390/jcm11226718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Ventricular arrhythmias are a common clinical manifestation in patients with cardiac sarcoidosis (CS) and other arrhythmogenic inflammatory cardiomyopathies (AIC). The management of sustained ventricular arrhythmias in these patients presents unique challenges. Current therapies include immunosuppressive, antiarrhythmic agents, and catheter ablation. Significant progress has been made in deciphering the importance of patient selection for ablation, systematic preablation evaluation, and optimal ablation timing, as well as ablation approaches and techniques. In this overview, we discuss the evaluation and management of ventricular arrhythmias in patients with CS, focusing on catheter ablation, which has evolved into an effective approach in reducing the burden of ventricular arrhythmias in these patients in the context of multifaceted treatment along with medical therapies.
Collapse
|
11
|
Kumar S, Narasimhan C. Diagnosis and management of Granulomatous Myocarditis. Indian Pacing Electrophysiol J 2022; 22:179-181. [PMID: 35777855 DOI: 10.1016/j.ipej.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Sharath Kumar
- Department of Electrophysiology, Asian Institute of Gastroenterology, Gachibowli, Hyderabad, India
| | - Calambur Narasimhan
- Department of Electrophysiology, Asian Institute of Gastroenterology, Gachibowli, Hyderabad, India.
| |
Collapse
|
12
|
Meta-Analysis of Catheter Ablation Outcomes in Patients With Cardiac Sarcoidosis Refractory Ventricular Tachycardia. Am J Cardiol 2022; 174:136-142. [PMID: 35504741 DOI: 10.1016/j.amjcard.2022.03.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 01/27/2023]
Abstract
Cardiac sarcoidosis (CS) frequently leads to ventricular tachycardia (VT), which is often refractory to antiarrhythmic and/or immunosuppressive medications and requires catheter ablation. We conducted a systematic review and meta-analysis to evaluate the role of catheter ablation in patients with refractory VT undergoing catheter ablation. We searched PubMed, Embase, and Scopus databases from their inception to December 31, 2021 with search terms "cardiac sarcoidosis" AND "electrophysiological studies OR ablation." Fifteen studies were ultimately included for evaluation. Patient demographics, VT mapping, and acute and long-term procedural outcomes were extracted. A total of 15 studies were included in our meta-analysis, with a total of 401 patients, of whom 66% were male, with ages ranging from 39 to 64 years. A total of 95% of patients were on antiarrhythmics and 79% of patients were on immunosuppressants. Left ventricular ejection fraction ranged from 35% to 49% and procedure duration ranged from 269 to 462 minutes. Ablation was reported using both irrigated and nonirrigated catheter tips. A total of 25% of patients (84/339) underwent repeat ablation. Acute procedural success was achieved in 57% (161/285). Procedure complications occurred in 5.7% (17/297) procedures. VT recurrence after first ablation was 55% (confidence interval 48% to 63%, 213/401); VT recurrence after multiple ablations was 37% (81/220). The composite end point of death, heart transplant, and left ventricular assist device implantation was 21% (confidence interval 14% to 30%, 55/297). In conclusion, catheter ablation is a useful modality in patients with CS with refractory VT. However, patients with CS presenting with refractory VT after undergoing VT ablation carry a poor prognosis.
Collapse
|
13
|
Siontis KC, Santangeli P, Muser D, Marchlinski FE, Zeppenfeld K, Hoogendoorn JC, Narasimhan C, Sauer WH, Zipse MM, Kapa S, Vedantham V, Rosenthal DG, Robinson MR, Patton KK, Murgatroyd F, Chicos AB, Soejima K, Roukoz H, Sacher F, Bhan A, Appelbaum J, Dickfeld T, Mankad P, Ellenbogen KA, Kron J, Kim HM, Froehlich J, Eagle KA, Bogun FM, Crawford TC. Outcomes Associated With Catheter Ablation of Ventricular Tachycardia in Patients With Cardiac Sarcoidosis. JAMA Cardiol 2021; 7:175-183. [PMID: 34787643 DOI: 10.1001/jamacardio.2021.4738] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Ventricular tachycardia (VT) is associated with high mortality in patients with cardiac sarcoidosis (CS), and medical management of CS-associated VT is limited by high failure rates. The role of catheter ablation has been investigated in small, single-center studies. Objective To investigate outcomes associated with VT ablation in patients with CS. Design, Setting, and Participants This cohort study from the Cardiac Sarcoidosis Consortium registry (2003-2019) included 16 tertiary referral centers in the US, Europe, and Asia. A total of 158 consecutive patients with CS and VT were included (33% female; mean [SD] age, 52 [11] years; 53% with ejection fraction [EF] <50%). Exposures Catheter ablation of CS-associated VT and, as appropriate, medical treatment. Main Outcomes and Measures Immediate and short-term outcomes included procedural success, elimination of VT storm, and reduction in defibrillator shocks. The primary long-term outcome was the composite of VT recurrence, heart transplant (HT), or death. Results Complete procedural success (no inducible VT postablation) was achieved in 85 patients (54%). Sixty-five patients (41%) had preablation VT storm that did not recur postablation in 53 (82%). Defibrillator shocks were significantly reduced from a median (IQR) of 2 (1-5) to 0 (0-0) in the 30 days before and after ablation (P < .001). During median (IQR) follow-up of 2.5 (1.1-4.9) years, 73 patients (46%) experienced VT recurrence and 81 (51%) experienced the composite primary outcome. One- and 2-year rates of survival free of VT recurrence, HT, or death were 60% and 52%, respectively. EF less than 50% and myocardial inflammation on preprocedural 18F-fluorodeoxyglucose positron emission tomography were significantly associated with adverse prognosis in multivariable analysis for the primary outcome (HR, 2.24; 95% CI, 1.37-3.64; P = .001 and HR, 2.93; 95% CI, 1.31-6.55; P = .009, respectively). History of hypertension was associated with a favorable long-term outcome (adjusted HR, 0.51; 95% CI, 0.28-0.92; P = .02). Conclusions and Relevance In this observational study of selected patients with CS and VT, catheter ablation was associated with reductions in defibrillator shocks and recurrent VT storm. Preablation LV dysfunction and myocardial inflammation were associated with adverse long-term prognosis. These data support the role of catheter ablation in conjunction with medical therapy in the management of CS-associated VT.
Collapse
Affiliation(s)
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Daniele Muser
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Jarieke C Hoogendoorn
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | | | - William H Sauer
- Section of Cardiac Electrophysiology, Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew M Zipse
- Section of Cardiac Electrophysiology, University of Colorado, Aurora
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Francis Murgatroyd
- Department of Cardiology, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Alexandru B Chicos
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Henri Roukoz
- Division of Cardiology, University of Minnesota, Minneapolis
| | - Frederic Sacher
- Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, University of Bordeaux, Bordeaux, France
| | - Adarsh Bhan
- Heart Vascular Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Jason Appelbaum
- Division of Cardiology, University of Maryland School of Medicine, Baltimore
| | - Timm Dickfeld
- Division of Cardiology, University of Maryland School of Medicine, Baltimore
| | - Pranav Mankad
- Division of Cardiology, Virginia Commonwealth University, Richmond
| | | | - Jordana Kron
- Division of Cardiology, Virginia Commonwealth University, Richmond
| | - Hyungjin Myra Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - James Froehlich
- Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan, Ann Arbor
| | - Kim A Eagle
- Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan, Ann Arbor
| | - Frank M Bogun
- Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan, Ann Arbor
| | - Thomas C Crawford
- Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan, Ann Arbor
| |
Collapse
|
14
|
Abstract
Sarcoidosis is a multisystem disease of unknown cause with heterogenous clinical manifestations and variable course. Spontaneous remissions occur in some patients while others have progressive disease impacting survival, organ function, and quality of life. Four high-risk sarcoidosis phenotypes associated with chronic inflammation have recently been identified as high-priority areas for research. These include treatment-refractory pulmonary disease, cardiac sarcoidosis, neurosarcoidosis and multiorgan sarcoidosis. Significant gaps currently exist in understanding of these high-risk manifestations of sarcoidosis, including their natural history, diagnostic criteria, biomarkers, and the treatment strategy such as the ideal agent, optimal dose and treatment duration. The use of registries with well-phenotyped patients is a critical first step to study high-risk sarcoidosis manifestations systematically. We review the diagnostic and treatment approach to high-risk sarcoidosis manifestations. Appropriately identifying these disease sub-groups will help enroll well-phenotyped patients in sarcoidosis registries and clinical trials, a necessary step to narrow existing gaps in understanding of this enigmatic disease.
Collapse
|
15
|
Kafil TS, Sparrow R, Khan HR, Manian U, Elrayes M, Bagur R, Tzemos N. Intravenous Methylprednisolone for Ventricular Tachycardia Electrical Storm in Cardiac Sarcoidosis: Case Series and 1-Year Follow-up. JACC Clin Electrophysiol 2021; 7:536-537. [PMID: 33888271 DOI: 10.1016/j.jacep.2020.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/09/2020] [Accepted: 12/02/2020] [Indexed: 12/01/2022]
|
16
|
Viwe M, Nery P, Birnie DH. Management of ventricular tachycardia in patients with cardiac sarcoidosis. Heart Rhythm O2 2021; 2:412-422. [PMID: 34430947 PMCID: PMC8369307 DOI: 10.1016/j.hroo.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease with 2 different phases (inflammation and scar). In the current era of targeted use of implantable cardioverter-defibrillators and modern heart failure therapy, recent data indicate the prognosis of cardiac sarcoidosis (CS) is much improved, and hence more patients are presenting with recurrent ventricular tachycardia (VT). This review highlights our current understanding of the pathophysiology and management of ventricular arrhythmias in CS with the major focus on indications, techniques, and outcomes of ablation. It is likely macroreentry phenomena around areas of fibrosis is the most frequent mechanism of ventricular arrhythmia in CS. It is also possible that inflammation may play a role in initiating reentry with ventricular ectopy in CS patients, or by slowing conduction in diseased tissue. The best available data would suggest annual rates of VT of perhaps 1%-2% and 10%-15% in patients with initially clinically silent and clinically manifest disease, respectively. Current guidelines recommend a stepwise approach to VT management. The first suggested step is treatment with immunosuppression if there is evidence of active inflammation. Antiarrhythmic medications are often started at the same time, with catheter ablation considered if VT cannot be controlled. Activation and entrainment mapping and ablation are favored in the setting of hemodynamically tolerated VT. Substrate ablation targets areas of abnormal electrogram and favorable pace mapping using linear and/or cluster lesion sets with the goal of abolishing critical isthmuses and/or blocking VT exit sites. Epicardial mapping ablation is required in 20%-35% of cases. In general, more morphologies of VT are induced (often 3-4) and subsequent outcomes (recurrence rates 40%-50%) are less favorable than in other forms of nonischemic cardiomyopathy. The prognosis of CS is much improved and, as a result, more patients are developing VT during follow-up. Likely principally related to the complex disease substrate, VT ablation is technically challenging, with moderate outcomes, and much remains to be learned.
Collapse
Affiliation(s)
- Mtwesi Viwe
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Pablo Nery
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - David H. Birnie
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| |
Collapse
|
17
|
Karki R, Janga C, Deshmukh AJ. Arrhythmias Associated with Inflammatory Cardiomyopathies. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:76. [PMID: 33230384 PMCID: PMC7674576 DOI: 10.1007/s11936-020-00871-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/21/2022]
Abstract
Purpose of review To provide an approach to the diagnosis and treatment of arrhythmias associated with inflammatory cardiomyopathies. Recent findings Inflammatory cardiomyopathies are increasingly recognized as the etiology of both ventricular and supraventricular arrhythmias. There have been recent studies providing novel insights into the pathogenesis of arrhythmias in inflammatory cardiomyopathies and exploring the role of various diagnostic tools and treatment strategies. Summary Patients with inflammatory cardiomyopathies often present with one or more arrhythmias, including atrioventricular block, atrial and ventricular tachyarrhythmias, and occasionally sudden cardiac death. Given dynamic pathophysiology and heterogeneous presentation, the management of arrhythmias in these patients presents unique challenges. We review the current approach to the diagnosis and treatment of arrhythmias in this challenging cohort of patients with an emphasis on cardiac sarcoidosis. Supplementary Information The online version of this article (10.1007/s11936-020-00871-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Roshan Karki
- Division of Cardiovascular Disease, Mayo Clinic, 200 1st Street, Rochester, MN 55905 USA
| | - Chaitra Janga
- Division of Cardiovascular Disease, Mayo Clinic, 200 1st Street, Rochester, MN 55905 USA
| | - Abhishek J Deshmukh
- Division of Cardiovascular Disease, Mayo Clinic, 200 1st Street, Rochester, MN 55905 USA
| |
Collapse
|