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Lenarczyk R, Zeppenfeld K, Tfelt-Hansen J, Heinzel FR, Deneke T, Ene E, Meyer C, Wilde A, Arbelo E, Jędrzejczyk-Patej E, Sabbag A, Stühlinger M, di Biase L, Vaseghi M, Ziv O, Bautista-Vargas WF, Kumar S, Namboodiri N, Henz BD, Montero-Cabezas J, Dagres N. 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. Europace 2024; 26:euae049. [PMID: 38584423 PMCID: PMC10999775 DOI: 10.1093/europace/euae049] [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] [Received: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/09/2024] Open
Abstract
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.
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Affiliation(s)
- Radosław Lenarczyk
- Medical University of Silesia, Division of Medical Sciences, Department of Cardiology and Electrotherapy, Silesian Center for Heart Diseases, Skłodowskiej-Curie 9, 41-800 Zabrze, Poland
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- The Department of Forensic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frank R Heinzel
- Cardiology, Angiology, Intensive Care, Städtisches Klinikum Dresden Campus Friedrichstadt, Dresden, Germany
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
- Clinic for Electrophysiology, Klinikum Nuernberg, University Hospital of the Paracelsus Medical University, Nuernberg, Germany
| | - Elena Ene
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Christian Meyer
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Arthur Wilde
- Department of Cardiology, Amsterdam UMC University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ewa Jędrzejczyk-Patej
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Markus Stühlinger
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Luigi di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrythmia Center, Division of Cardiology, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Ohad Ziv
- Case Western Reserve University, Cleveland, OH, USA
- The MetroHealth System Campus, Cleveland, OH, USA
| | | | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | | | - Benhur Davi Henz
- Instituto Brasilia de Arritmias-Hospital do Coração do Brasil-Rede Dor São Luiz, Brasilia, Brazil
| | - Jose Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Trohman RG. Etiologies, Mechanisms, Management, and Outcomes of Electrical Storm. J Intensive Care Med 2024; 39:99-117. [PMID: 37731333 DOI: 10.1177/08850666231192050] [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: 09/22/2023]
Abstract
Electrical storm (ES) is characterized by three or more discrete sustained ventricular tachyarrhythmia episodes occurring within a limited time frame (generally ≤ 24 h) or an incessant ventricular tachyarrhythmia lasting > 12 h. In patients with an implantable cardioverterdefibrillator (ICD), ES is defined as three or more appropriate device therapies, separated from each other by at least 5 min, which occur within a 24-h period. ES may constitute a medical emergency, depending on the number arrhythmic episodes, their duration, the type, and the cycle length of the ventricular arrhythmias, as well as the underlying ventricular function. This narrative review was facilitated by a search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1999 and 2023. ES was searched using the terms mechanisms, genetics, channelopathies, management, pharmacological therapy, sedation, neuraxial modulation, cardiac sympathetic denervation, ICDs, and structural heart disease. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. This manuscript examines the current strategies available to treat ES and compares pharmacological and invasive treatment strategies to diminish ES recurrence, morbidity, and mortality.
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Affiliation(s)
- Richard G Trohman
- Section of Electrophysiology, Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
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3
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Dusi V, Vaseghi M. Neuronal sympathetic block for ventricular arrhythmias: one size may not fit all. Europace 2023; 25:euad314. [PMID: 37889145 PMCID: PMC10637298 DOI: 10.1093/europace/euad314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126 Turin, Italy
| | - Marmar Vaseghi
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
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4
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 294] [Impact Index Per Article: 294.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Yang PC, Rose A, DeMarco KR, Dawson JRD, Han Y, Jeng MT, Harvey RD, Santana LF, Ripplinger CM, Vorobyov I, Lewis TJ, Clancy CE. A multiscale predictive digital twin for neurocardiac modulation. J Physiol 2023; 601:3789-3812. [PMID: 37528537 PMCID: PMC10528740 DOI: 10.1113/jp284391] [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: 01/17/2023] [Accepted: 07/11/2023] [Indexed: 08/03/2023] Open
Abstract
Cardiac function is tightly regulated by the autonomic nervous system (ANS). Activation of the sympathetic nervous system increases cardiac output by increasing heart rate and stroke volume, while parasympathetic nerve stimulation instantly slows heart rate. Importantly, imbalance in autonomic control of the heart has been implicated in the development of arrhythmias and heart failure. Understanding of the mechanisms and effects of autonomic stimulation is a major challenge because synapses in different regions of the heart result in multiple changes to heart function. For example, nerve synapses on the sinoatrial node (SAN) impact pacemaking, while synapses on contractile cells alter contraction and arrhythmia vulnerability. Here, we present a multiscale neurocardiac modelling and simulator tool that predicts the effect of efferent stimulation of the sympathetic and parasympathetic branches of the ANS on the cardiac SAN and ventricular myocardium. The model includes a layered representation of the ANS and reproduces firing properties measured experimentally. Model parameters are derived from experiments and atomistic simulations. The model is a first prototype of a digital twin that is applied to make predictions across all system scales, from subcellular signalling to pacemaker frequency to tissue level responses. We predict conditions under which autonomic imbalance induces proarrhythmia and can be modified to prevent or inhibit arrhythmia. In summary, the multiscale model constitutes a predictive digital twin framework to test and guide high-throughput prediction of novel neuromodulatory therapy. KEY POINTS: A multi-layered model representation of the autonomic nervous system that includes sympathetic and parasympathetic branches, each with sparse random intralayer connectivity, synaptic dynamics and conductance based integrate-and-fire neurons generates firing patterns in close agreement with experiment. A key feature of the neurocardiac computational model is the connection between the autonomic nervous system and both pacemaker and contractile cells, where modification to pacemaker frequency drives initiation of electrical signals in the contractile cells. We utilized atomic-scale molecular dynamics simulations to predict the association and dissociation rates of noradrenaline with the β-adrenergic receptor. Multiscale predictions demonstrate how autonomic imbalance may increase proclivity to arrhythmias or be used to terminate arrhythmias. The model serves as a first step towards a digital twin for predicting neuromodulation to prevent or reduce disease.
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Affiliation(s)
- Pei-Chi Yang
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
| | - Adam Rose
- Department of Mathematics, University of California Davis, Davis, CA
| | - Kevin R. DeMarco
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
| | - John R. D. Dawson
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
| | - Yanxiao Han
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
| | - Mao-Tsuen Jeng
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
| | | | - L. Fernando Santana
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
| | | | - Igor Vorobyov
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
| | - Timothy J. Lewis
- Department of Mathematics, University of California Davis, Davis, CA
| | - Colleen E. Clancy
- Department of Physiology and Membrane Biology, University of California Davis, Davis, CA
- Center for Precision Medicine and Data Science, University of California Davis, Sacramento, CA
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Kariki O, Georgopoulos M, Katsillis N, Chatziantoniou A, Koskina S, Zygouri A, Saplaouras A, Bazoukis G, Gkouziouta A, Vlachos K, Dragasis S, Mililis P, Adamopoulos S, Efremidis M, Letsas KP. Contemporary management of ventricular arrhythmias in heart failure. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2023; 13:207-221. [PMID: 37736352 PMCID: PMC10509449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 07/04/2023] [Indexed: 09/23/2023]
Abstract
Enhanced ventricular arrhythmogenesis is commonly experienced by patients in the end-stage of heart failure spectrum. A high burden of ventricular arrhythmias can affect the ventricular systolic function, lead to unexpected hospitalizations and further deteriorate the prognosis. Management of ventricular arrhythmias in this population is challenging. Implantable cardioverter-defibrillators are protective for the immediate termination of life-threatening arrhythmias but they have no impact in reducing the arrhythmic burden. Combination treatment with invasive (catheter ablation, mechanical hemodynamic support, sympathetic denervation) and noninvasive (antiarrhythmic drugs, medical therapy for heart failure, programming of implantable devices) therapies is commonly required. The aim of this review is to present the available therapeutic options, with main focus on recently published data for catheter ablation and provide a stepwise treatment approach.
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Affiliation(s)
- Ourania Kariki
- Department of Cardiology, Onassis Cardiac Surgery CenterAthens, Greece
| | | | - Nikitas Katsillis
- Department of Cardiology, Onassis Cardiac Surgery CenterAthens, Greece
| | | | - Stavroula Koskina
- Department of Cardiology, Onassis Cardiac Surgery CenterAthens, Greece
| | - Andromahi Zygouri
- Department of Cardiology, Onassis Cardiac Surgery CenterAthens, Greece
| | | | - George Bazoukis
- Department of Cardiology, Larnaca General HospitalLarnaca, Cyprus
| | | | | | | | | | | | - Michael Efremidis
- Department of Cardiology, Onassis Cardiac Surgery CenterAthens, Greece
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7
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van Weperen VYH, Ripplinger CM, Vaseghi M. Autonomic control of ventricular function in health and disease: current state of the art. Clin Auton Res 2023; 33:491-517. [PMID: 37166736 PMCID: PMC10173946 DOI: 10.1007/s10286-023-00948-8] [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: 01/02/2023] [Accepted: 04/20/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Cardiac autonomic dysfunction is one of the main pillars of cardiovascular pathophysiology. The purpose of this review is to provide an overview of the current state of the art on the pathological remodeling that occurs within the autonomic nervous system with cardiac injury and available neuromodulatory therapies for autonomic dysfunction in heart failure. METHODS Data from peer-reviewed publications on autonomic function in health and after cardiac injury are reviewed. The role of and evidence behind various neuromodulatory therapies both in preclinical investigation and in-use in clinical practice are summarized. RESULTS A harmonic interplay between the heart and the autonomic nervous system exists at multiple levels of the neuraxis. This interplay becomes disrupted in the setting of cardiovascular disease, resulting in pathological changes at multiple levels, from subcellular cardiac signaling of neurotransmitters to extra-cardiac, extra-thoracic remodeling. The subsequent detrimental cycle of sympathovagal imbalance, characterized by sympathoexcitation and parasympathetic withdrawal, predisposes to ventricular arrhythmias, progression of heart failure, and cardiac mortality. Knowledge on the etiology and pathophysiology of this condition has increased exponentially over the past few decades, resulting in a number of different neuromodulatory approaches. However, significant knowledge gaps in both sympathetic and parasympathetic interactions and causal factors that mediate progressive sympathoexcitation and parasympathetic dysfunction remain. CONCLUSIONS Although our understanding of autonomic imbalance in cardiovascular diseases has significantly increased, specific, pivotal mediators of this imbalance and the recognition and implementation of available autonomic parameters and neuromodulatory therapies are still lagging.
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Affiliation(s)
- Valerie Y H van Weperen
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | | | - Marmar Vaseghi
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA.
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8
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Dusi V, Angelini F, Gravinese C, Frea S, De Ferrari GM. Electrical storm management in structural heart disease. Eur Heart J Suppl 2023; 25:C242-C248. [PMID: 37125278 PMCID: PMC10132591 DOI: 10.1093/eurheartjsupp/suad048] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Electrical storm (ES) is a life-threatening condition characterized by at least three separate episodes of ventricular arrhythmias (VAs) over 24 h, each requiring therapeutic intervention, including implantable cardioverter defibrillator (ICD) therapies. Patients with ICDs in secondary prevention are at higher risk of ES and the most common presentation is that of scar-related monomorphic VAs. Electrical storm represents a major unfavourable prognostic marker in the history of patients with structural heart disease, with an associated two- to five-fold increase in mortality, heart transplant, and heart failure hospitalization. Early recognition and prompt treatment are crucial to improve the outcome. Yet, ES management is complex and requires a multidisciplinary approach and well-defined protocols and networks to guarantee a proper patient care. Acute phase stabilization should include a comprehensive clinical assessment, resuscitation and sedation management skills, ICD reprogramming, and acute sympathetic modulation, while the sub-acute/chronic phase requires a comprehensive heart team evaluation to define the better treatment option according to the haemodynamic and overall patient's condition and the type of VAs. Advanced anti-arrhythmic strategies, not mutually exclusive, include invasive ablation, cardiac sympathetic denervation, and, for very selected cases, stereotactic ablation. Each of these aspects, as well as the new European Society of Cardiology guidelines recommendations, will be discussed in the present review.
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Affiliation(s)
| | | | - Carol Gravinese
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Corso Bramante 88, 10126 Turin, Italy
| | - Simone Frea
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Corso Bramante 88, 10126 Turin, Italy
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Sridharan A, Bradfield JS, Shivkumar K, Ajijola OA. Autonomic nervous system and arrhythmias in structural heart disease. Auton Neurosci 2022; 243:103037. [DOI: 10.1016/j.autneu.2022.103037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022]
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Baldi E, Conte G, Zeppenfeld K, Lenarczyk R, Guerra JM, Farkowski MM, de Asmundis C, Boveda S. Contemporary management of ventricular electrical storm in Europe: results of a European Heart Rhythm Association Survey. Europace 2022; 25:1277-1283. [PMID: 36196613 PMCID: PMC10105853 DOI: 10.1093/europace/euac151] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Electrical storm (ES) is a predictor of mortality, and its treatment is challenging. Moreover, not all potential therapeutic strategies are available in all hospitals, and a standardized approach among European centres is lacking. The aim of this European Heart Rhythm Association (EHRA) survey was to assess the current management of patients with ES both in the acute and post-acute phases in 102 different European centres. A 20-item online questionnaire was sent out to the EHRA Research Network Centres. The median number of patients with ES treated annually per centre is 10 (IQR 5-15). The possibility of using autonomic modulation (e.g. percutaneous stellate ganglion block or thoracic epidural anaesthesia) for the acute ES treatment is available in only 29.3% of the centres. Moreover, although over 80% of centres perform ventricular tachycardia ablation, this procedure is available 24/7 in only 16.5% of the hospitals. There is a significant heterogeneity among centres regarding the availability of AADs and their use before deciding to proceed with a non-AAD strategy; specifically, 4.4% of centres use only one drug, 33.3% use two drugs, and 12.2% >two drugs, while about 50% of the centres decide based on individual patient's characteristics. Regarding the type of AADs used for the acute and post-acute management of ES patients, important variability is reported depending upon the underlying heart disease. Most patients considered for percutaneous ablation have structural heart disease. Only 46% of centres refer patients to psychological counselling after ES.
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Affiliation(s)
- Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulio Conte
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete 48, Lugano 6900, Switzerland
| | - Katja Zeppenfeld
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Leiden, The Netherlands
| | - Radosław Lenarczyk
- Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, The Medical University of Silesia, Zabrze, Poland
| | - Jose M Guerra
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, IIB SANT PAU, CIBERCV, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Michal M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Serge Boveda
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium.,Cardiology-Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
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Levis M, Dusi V, Magnano M, Cerrato M, Gallio E, Depaoli A, Ferraris F, De Ferrari GM, Ricardi U, Anselmino M. A case report of long-term successful stereotactic arrhythmia radioablation in a cardiac contractility modulation device carrier with giant left atrium, including a detailed dosimetric analysis. Front Cardiovasc Med 2022; 9:934686. [PMID: 36072883 PMCID: PMC9441661 DOI: 10.3389/fcvm.2022.934686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/25/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Catheter ablation (CA) is the current standard of care for patients suffering drug-refractory monomorphic ventricular tachycardias (MMVTs). Yet, despite significant technological improvements, recurrences remain common, leading to increased morbidity and mortality. Stereotactic arrhythmia radioablation (STAR) is increasingly being adopted to overcome the limitations of conventional CA, but its safety and efficacy are still under evaluation. Case presentation We hereby present the case of a 73-year-old patient implanted with a mitral valve prosthesis, a cardiac resynchronization therapy-defibrillator, and a cardiac contractility modulation device, who was successfully treated with STAR for recurrent drug and CA-resistant MMVT in the setting of advanced heart failure and a giant left atrium. We report a 2-year follow-up and a detailed dosimetric analysis. Conclusion Our case report supports the early as well as the long-term efficacy of 25 Gy single-session STAR. Despite the concomitant severe heart failure, with an overall heart minus planned target volume mean dosage below 5 Gy, no major detrimental cardiac side effects were detected. To the best of our knowledge, our dosimetric analysis is the most accurate reported so far in the setting of STAR, particularly for what concerns cardiac substructures and coronary arteries. A shared dosimetric planning among centers performing STAR will be crucial in the next future to fully disclose its safety profile.
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Affiliation(s)
- Mario Levis
- Department of Oncology, University of Turin, Turin, Italy
| | - Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Massimo Magnano
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marzia Cerrato
- Department of Oncology, University of Turin, Turin, Italy
| | - Elena Gallio
- Medical Physics Unit, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Alessandro Depaoli
- Department of Radiology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Federico Ferraris
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
- *Correspondence: Gaetano Maria De Ferrari
| | | | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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12
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Miki Y, Yoshimura S, Sasaki T, Takizawa R, Kimura K, Haraguchi Y, Sasaki W, Kishi S, Nakatani Y, Kaseno K, Goto K, Take Y, Nakamura K, Niwamae N, Kamiyoshihara M, Naito S. Bilateral Cardiac Sympathetic Denervation for Treatment-Resistant Ventricular Arrhythmias in Heart Failure Patients with a Reduced Ejection Fraction. Int Heart J 2022; 63:692-699. [PMID: 35908853 DOI: 10.1536/ihj.21-601] [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] [Indexed: 12/13/2022]
Abstract
The sympathetic nervous system plays an important role in life-threatening ventricular arrhythmias (VAs). Bilateral cardiac sympathetic denervation (BCSD) is performed for refractory VAs. We sought to assess our institutional experience with BCSD in managing treatment-resistant monomorphic ventricular tachycardia (MMVT) in heart failure patients with a reduced ejection fraction (HFrEF).Four patients with HFrEF (EF 30.0 ± 8.2%, New York Heart Association [NYHA] class IV 1) underwent BCSD for MMVT (VT storm 3, repetitive VT requiring implantable cardioverter defibrillator [ICD] therapy 1) refractory to antiarrhythmic drugs, catheter ablation and ICD therapy. BCSD was effective for suppressing VT in 3 patients for whom deep sedation was effective for suppressing VT. One patient remained alive after 14 months of follow-up without episodes of VT. One patient died of acute myocardial infarction before discharge and 1 patient died from unknown cause at 3 days post-discharge. In contrast, BCSD was completely ineffective for suppressing VT in a patient with NYHA class IV for whom deep sedation and stellate ganglion block were ineffective. This patient died on the 10th post-CSD day, despite left ventricular assist device implantation. In all cases, BCSD was successfully performed without procedure-related complications.Despite the limited number of cases, our results showed that BCSD in patients with HFrEF suppressed refractory MMVT in acute-phase except for a patient with NYHA class IV; however, the prognoses were not good. BCSD may be a treatment option at an earlier stage of NYHA and a bridge to orthotopic heart transplantation, even if BCSD is effective for suppressing VAs.
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Affiliation(s)
- Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Ryoya Takizawa
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kohki Kimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Yosuke Nakatani
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Nogiku Niwamae
- Department of Cardiovascular Medicine, Japanese Red Cross Maebashi Hospital
| | | | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
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Abstract
Proper management of patients affected by genetic disorders causing life-threatening arrhythmias is important for several reasons, including even societal ones, given the predominantly young age of those affected. Incorrect management often has dire consequences, ranging from unnecessary psychologic damage for the patients whose life becomes too limited by the fear of sudden death to equally avoidable tragedies when the entire armamentarium of effective therapies is not fully utilized. In this review, we focus primarily on long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT) and deal specifically with the clinical impact of the most commonly used cardiac sympathetic denervation (CSD), namely left cardiac sympathetic denervation (LCSD). The two of us have used LCSD in the management of our patients with either LQTS or CPVT for a very long time and have been involved in ∼500 such interventions. It is on the basis of this personal and direct experience that we wish to share our views with clinical cardiologists and electrophysiologists, adult and paediatric, and with genetic cardiologists. We will begin by reviewing the history and rationale underlying sympathetic denervation therapy and will continue with a disease-specific intensification of therapy, and then with a discussion on how the impressive efficacy of LCSD should translate into guideline-directed therapy in both current and future guidelines, in order to upgrade the quality of care in the era of precision medicine.
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Affiliation(s)
- Peter J. Schwartz
- Corresponding authors. Tel: +39 02619113408, Fax: +39 02619113411, Emails: , (P.J.S.); Tel: +1 507 284 0101, , Twitter: @MJAckermanMDPhD (M.J.A.)
| | - Michael J. Ackerman
- Corresponding authors. Tel: +39 02619113408, Fax: +39 02619113411, Emails: , (P.J.S.); Tel: +1 507 284 0101, , Twitter: @MJAckermanMDPhD (M.J.A.)
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14
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Kahle AK, Jungen C, Alken FA, Scherschel K, Willems S, Pürerfellner H, Chen S, Eckardt L, Meyer C. Management of ventricular tachycardia in patients with ischaemic cardiomyopathy: contemporary armamentarium. Europace 2021; 24:538-551. [PMID: 34967892 DOI: 10.1093/europace/euab274] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 01/10/2023] Open
Abstract
Worldwide, ∼4 million people die from sudden cardiac death every year caused in more than half of the cases by ischaemic cardiomyopathy (ICM). Prevention of sudden cardiac death after myocardial infarction by implantation of a cardioverter-defibrillator (ICD) is the most common, even though not curative, therapy to date. Optimized ICD programming should be strived for in order to decrease the incidence of ICD interventions. Catheter ablation reduces the recurrence of ventricular tachycardias (VTs) and is an important adjunct to sole ICD-based treatment or pharmacological antiarrhythmic therapy in patients with ICM, as conclusively demonstrated by seven randomized controlled trials (RCTs) in the last two decades. However, none of the conducted trials was powered to reveal a survival benefit for ablated patients as compared to controls. Whereas thorough consideration of an early approach is necessary following two recent RCTs (PAUSE-SCD, BERLIN VT), catheter ablation is particularly recommended in patients with recurrent VT after ICD therapy. In this context, novel, pathophysiologically driven ablation strategies referring to deep morphological and functional substrate phenotyping based on high-resolution mapping and three-dimensional visualization of scars appear promising. Emerging concepts like sympathetic cardiac denervation as well as radioablation might expand the therapeutical armamentarium especially in patients with therapy-refractory VT. Randomized controlled trials are warranted and on the way to investigate how these translate into improved patient outcome. This review summarizes therapeutic strategies currently available for the prevention of VT recurrences, the optimal timing of applicability, and highlights future perspectives after a PAUSE in BERLIN.
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Affiliation(s)
- Ann-Kathrin Kahle
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Christiane Jungen
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany.,Clinic for Cardiology, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Fares-Alexander Alken
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Katharina Scherschel
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Stephan Willems
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany.,Department of Cardiology and Internal Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmühlenstrasse 5, 20099 Hamburg, Germany
| | - Helmut Pürerfellner
- Department of Electrophysiology, Academic Teaching Hospital, Ordensklinikum Linz Elisabethinen, Fadingerstraße 1, 4020 Linz, Austria
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien (CCB), Frankfurt Academy For Arrhythmias (FAFA), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Wilhelm-Epstein Straße 4, 60431 Frankfurt am Main, Germany
| | - Lars Eckardt
- Department for Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Christian Meyer
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
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15
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Clyburn C, Sepe JJ, Habecker BA. What gets on the nerves of cardiac patients? Pathophysiological changes in cardiac innervation. J Physiol 2021; 600:451-461. [PMID: 34921407 PMCID: PMC8810748 DOI: 10.1113/jp281118] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/10/2021] [Indexed: 11/08/2022] Open
Abstract
The autonomic nervous system regulates cardiac function by balancing the actions of sympathetic and parasympathetic inputs to the heart. Intrinsic cardiac neurocircuits integrate these autonomic signals to fine-tune cardiac control, and sensory feedback loops regulate autonomic transmission in the face of external stimuli. These interconnected neural systems allow the heart to adapt to constantly changing circumstances that range from simple fluctuations in body position to running a marathon. The cardiac reflexes that serve to maintain homeostasis in health are disrupted in many disease states. This is often characterized by increased sympathetic and decreased parasympathetic transmission. Studies of cardiovascular disease reveal remodelling of cardiac neurocircuits at several functional and anatomical levels. Central circuits change so that sympathetic pathways become hyperactive, while parasympathetic circuits exhibit decreased activity. Peripheral sensory nerves also become hyperactive in disease, which increases patients' risk for poor cardiac outcomes. Injury and disease also alter the types of neurotransmitters and neuropeptides released by autonomic nerves in the heart, and can lead to regional hyperinnervation (increased nerve density) or denervation (decreased nerve density) of cardiac tissue. The mechanisms responsible for neural remodelling are not fully understood, but neurotrophins and inflammatory cytokines are likely involved. Areas of active investigation include the role of immune cells and inflammation in neural remodelling, as well as the role of glia in modulating peripheral neuronal activity. Our growing understanding of autonomic dysfunction in disease has facilitated development of new therapeutic strategies to improve health outcomes.
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Affiliation(s)
- Courtney Clyburn
- Department of Chemical Physiology and Biochemistry, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph J Sepe
- Department of Chemical Physiology and Biochemistry, Oregon Health and Science University, Portland, Oregon, USA
| | - Beth A Habecker
- Department of Chemical Physiology and Biochemistry, Oregon Health and Science University, Portland, Oregon, USA
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16
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van Weperen VYH, Vos MA, Ajijola OA. Autonomic modulation of ventricular electrical activity: recent developments and clinical implications. Clin Auton Res 2021; 31:659-676. [PMID: 34591191 PMCID: PMC8629778 DOI: 10.1007/s10286-021-00823-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE This review aimed to provide a complete overview of the current stance and recent developments in antiarrhythmic neuromodulatory interventions, focusing on lifethreatening vetricular arrhythmias. METHODS Both preclinical studies and clinical studies were assessed to highlight the gaps in knowledge that remain to be answered and the necessary steps required to properly translate these strategies to the clinical setting. RESULTS Cardiac autonomic imbalance, characterized by chronic sympathoexcitation and parasympathetic withdrawal, destabilizes cardiac electrophysiology and promotes ventricular arrhythmogenesis. Therefore, neuromodulatory interventions that target the sympatho-vagal imbalance have emerged as promising antiarrhythmic strategies. These strategies are aimed at different parts of the cardiac neuraxis and directly or indirectly restore cardiac autonomic tone. These interventions include pharmacological blockade of sympathetic neurotransmitters and neuropeptides, cardiac sympathetic denervation, thoracic epidural anesthesia, and spinal cord and vagal nerve stimulation. CONCLUSION Neuromodulatory strategies have repeatedly been demonstrated to be highly effective and very promising anti-arrhythmic therapies. Nevertheless, there is still much room to gain in our understanding of neurocardiac physiology, refining the current neuromodulatory strategic options and elucidating the chronic effects of many of these strategic options.
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Affiliation(s)
- Valerie Y H van Weperen
- Department of Medical Physiology, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Center, UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, University of California, 100 Medical Plaza, Suite 660, Westwood Blvd, Los Angeles, CA, 90095-1679, USA
| | - Marc A Vos
- Department of Medical Physiology, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Center, UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, University of California, 100 Medical Plaza, Suite 660, Westwood Blvd, Los Angeles, CA, 90095-1679, USA.
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17
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Noordman ABP, Maass AH, Groenveld H, Mulder BA, Rienstra M, Blaauw Y. Myocardial Scar Characterization and Future Ventricular Arrhythmia in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter-Defibrillator. Front Cardiovasc Med 2021; 8:708406. [PMID: 34485409 PMCID: PMC8415981 DOI: 10.3389/fcvm.2021.708406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Implantable cardioverter-defibrillator (ICD) therapy is associated with several deleterious effects, which can be reduced by antiarrhythmic drugs or catheter ablation. However, it is largely unknown which patients might benefit from these therapies. Therefore, this study aimed to investigate whether myocardial scar characterization improves risk stratification for ventricular arrhythmia (VA) occurrence in patients with ischemic cardiomyopathy and an ICD. Methods: In this study, 82 patients with ischemic cardiomyopathy who received an ICD were enrolled retrospectively. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) images were analyzed using an investigational software tool to obtain quantitative data regarding the total scar, core, and border zone (BZ). Data regarding the QRS complex was obtained from electrocardiography (ECG). The primary endpoint was appropriate ICD therapy. Results: During a median follow-up duration of 3.98 years [interquartile range (IQR) 2.89–5.14 years], appropriate therapy occurred in 24 (29.3%) patients. Patients with appropriate ICD therapy had a significantly larger total scar mass [60.0 (IQR 41.2–73.4) vs. 43.3 (IQR 31.2–61.2) g; P = 0.009] and BZ mass [32.9 (IQR 26.9–42.4) vs. 24.5 (IQR 18.8–32.5) g; P = 0.001] than those without appropriate therapy. In multivariable Cox regression analyses, total scar mass [hazard ratio (HR) 1.02 [95% confidence interval (CI) 1.00–1.04]; P = 0.014] and BZ mass (HR 1.04 [95% CI 1.01–1.07]; P = 0.009) independently predicted appropriate ICD therapy. Core mass and the QRS complex, however, were not significantly associated with the primary endpoint. Conclusion: LGE-CMR-based, but not ECG-based myocardial scar characterization improves risk stratification for VA occurrence in patients with ischemic cardiomyopathy who received an ICD.
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Affiliation(s)
- Alwin B P Noordman
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Alexander H Maass
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Hessel Groenveld
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bart A Mulder
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel Rienstra
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Yuri Blaauw
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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18
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Nguyen HL, Vaseghi M. Confessions of a stressed heart: The brain-heart relationship is complicated. Trends Cardiovasc Med 2021; 32:178-179. [PMID: 33781895 DOI: 10.1016/j.tcm.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Heajung L Nguyen
- UCLA Cardiac Arrhythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095-1679, United States
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095-1679, United States.
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19
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Dusi V, Gornbein J, Do DH, Sorg JM, Khakpour H, Krokhaleva Y, Ajijola OA, Macias C, Bradfield JS, Buch E, Fujimura OA, Boyle NG, Yanagawa J, Lee JM, Shivkumar K, Vaseghi M. Arrhythmic Risk Profile and Outcomes of Patients Undergoing Cardiac Sympathetic Denervation for Recurrent Monomorphic Ventricular Tachycardia After Ablation. J Am Heart Assoc 2021; 10:e018371. [PMID: 33441022 PMCID: PMC7955320 DOI: 10.1161/jaha.120.018371] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Cardiac sympathetic denervation (CSD) has been used as a bailout strategy for refractory ventricular tachycardia (VT). Risk of VT recurrence in patients with scar‐related monomorphic VT referred for CSD and the extent to which CSD can modify this risk is unknown. We aimed to quantify arrhythmia recurrence risk and impact of CSD in this population. Methods and Results Adjusted competing risk time to event models were developed to adjust for risk of VT recurrence and sustained VT/implantable cardioverter–defibrillator shocks after VT ablation based on patient comorbidities at the time of VT ablation. Adjusted VT and implantable cardioverter–defibrillator shock recurrence rates were estimated for the subgroup who subsequently required CSD after ablation. The expected adjusted recurrence rates were then compared with the observed rates after CSD. Data from 381 patients with scar‐mediated monomorphic VT who underwent VT ablation were analyzed, excluding patients with polymorphic VT. Sixty eight patients underwent CSD for recurrent VT. CSD reduced the expected adjusted VT recurrence rate by 36% (expected rate of 5.61 versus observed rate of 3.58 per 100 person‐months, P=0.01) and the sustained VT/implantable cardioverter–defibrillator shock rates by 34% (expected rate of 4.34 versus observed 2.85 per 100 person‐months, P=0.03). The median number of sustained VT/implantable cardioverter–defibrillator shocks in the year before versus the year after CSD was reduced by 90% (10 versus 1, P<0.0001). Conclusions Patients referred for CSD for refractory scar‐mediated monomorphic VT are at a higher risk of VT recurrence after ablation as compared with those not requiring CSD, mostly because of their cardiac comorbidities. CSD significantly reduced both the expected risk of recurrences and VT burden.
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Affiliation(s)
- Veronica Dusi
- UCLA Cardiac Arrhythmia Center Los Angeles CA.,Department of Molecular Medicine University of Pavia Pavia Italy
| | - Jeffrey Gornbein
- Departments of Medicine and Computational Medicine University of California Los Angeles CA
| | - Duc H Do
- UCLA Cardiac Arrhythmia Center Los Angeles CA
| | | | | | | | | | | | | | - Eric Buch
- UCLA Cardiac Arrhythmia Center Los Angeles CA
| | | | | | - Jane Yanagawa
- Division of Thoracic Surgery Department of Surgery University of California Los Angeles CA
| | - Jay M Lee
- Division of Thoracic Surgery Department of Surgery University of California Los Angeles CA
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