TY - JOUR
T1 - Empiric ablation of polymorphic ventricular tachycardia/fibrillation in the absence of a mappable trigger
T2 - Prospective feasibility and efficacy of pacemap matching to defibrillator electrograms
AU - Salazar, Pablo
AU - Beaser, Andrew D.
AU - Upadhyay, Gaurav A.
AU - Aziz, Zaid
AU - Besser, Stephanie
AU - Shatz, Dalise Y.
AU - Nayak, Hemal M.
AU - Tung, Roderick
N1 - Funding Information:
Funding Sources: The authors have no funding sources to disclose. Disclosures: The authors have no conflicts of interest to disclose.
Publisher Copyright:
© 2021 Heart Rhythm Society
PY - 2022/4
Y1 - 2022/4
N2 - Background: Catheter ablation strategies for ventricular fibrillation (VF) and polymorphic ventricular tachycardia (PMVT) are not established when spontaneous triggers are rare or absent. Objective: The purpose of this study was to report the feasibility and efficacy of a novel empiric ablation strategy of pacemapping to stored implantable cardioverter-defibrillator (ICD) template electrograms (SITE) of the clinical premature ventricular contraction (PVC) trigger. Methods: Fifteen patients with drug-refractory VF/PMVT receiving defibrillator shocks without identifiable and mappable PVC triggers were prospectively analyzed. The protocol incorporated systematic pacemapping from known arrhythmogenic sites (moderator band/right ventricular [RV] papillary muscles, left conduction system/Purkinje network, outflow tracts) with real-time comparison between the paced ICD electrogram (EGM) morphology and SITE. Results: Regions within the left Purkinje network yielded the best pacemap match for the SITE of the clinical PVC trigger in 55% of ablation targets (left posterior fascicle 6, left septal fascicle 1, left anterior fascicle 5), followed by the RV moderator band region in 14% (n = 3), RV papillary muscles in 13% (n = 3), periaortic region in 14% (n = 3), and left ventricular anterolateral papillary muscle in 4% (n = 1). Freedom from ICD therapies off antiarrhythmic drug (AAD) was 64% at 6 months and 48% at 12 months. Shock burden was reduced from 4 (2–6) to 0 (0–1) (P = .001), and use of AADs was reduced from 2 (1–2) to 0 (0–1) (P = .001). Conclusion: In the absence of a mappable trigger, an empiric strategy of interrogating the Purkinje network, papillary muscles, and outflow tract regions by pacemap matching with SITE of the clinical PVC is feasible to guide ablation. A significant reduction in VF/PMVT therapy burden and AAD utilization was observed after a single procedure.
AB - Background: Catheter ablation strategies for ventricular fibrillation (VF) and polymorphic ventricular tachycardia (PMVT) are not established when spontaneous triggers are rare or absent. Objective: The purpose of this study was to report the feasibility and efficacy of a novel empiric ablation strategy of pacemapping to stored implantable cardioverter-defibrillator (ICD) template electrograms (SITE) of the clinical premature ventricular contraction (PVC) trigger. Methods: Fifteen patients with drug-refractory VF/PMVT receiving defibrillator shocks without identifiable and mappable PVC triggers were prospectively analyzed. The protocol incorporated systematic pacemapping from known arrhythmogenic sites (moderator band/right ventricular [RV] papillary muscles, left conduction system/Purkinje network, outflow tracts) with real-time comparison between the paced ICD electrogram (EGM) morphology and SITE. Results: Regions within the left Purkinje network yielded the best pacemap match for the SITE of the clinical PVC trigger in 55% of ablation targets (left posterior fascicle 6, left septal fascicle 1, left anterior fascicle 5), followed by the RV moderator band region in 14% (n = 3), RV papillary muscles in 13% (n = 3), periaortic region in 14% (n = 3), and left ventricular anterolateral papillary muscle in 4% (n = 1). Freedom from ICD therapies off antiarrhythmic drug (AAD) was 64% at 6 months and 48% at 12 months. Shock burden was reduced from 4 (2–6) to 0 (0–1) (P = .001), and use of AADs was reduced from 2 (1–2) to 0 (0–1) (P = .001). Conclusion: In the absence of a mappable trigger, an empiric strategy of interrogating the Purkinje network, papillary muscles, and outflow tract regions by pacemap matching with SITE of the clinical PVC is feasible to guide ablation. A significant reduction in VF/PMVT therapy burden and AAD utilization was observed after a single procedure.
KW - Ablation
KW - Pacemap
KW - Polymorphic tachycardia
KW - Premature ventricular contraction
KW - Ventricular fibrillation
KW - Ventricular tachycardia
UR - https://www.scopus.com/pages/publications/85121099338
UR - https://www.scopus.com/pages/publications/85121099338#tab=citedBy
U2 - 10.1016/j.hrthm.2021.10.025
DO - 10.1016/j.hrthm.2021.10.025
M3 - Article
C2 - 34757186
AN - SCOPUS:85121099338
SN - 1547-5271
VL - 19
SP - 527
EP - 535
JO - Heart Rhythm
JF - Heart Rhythm
IS - 4
ER -