Mapping and ablation of idiopathic ventricular fibrillation.

Michel HaïSsaguerre,StéPhane Garrigue,Dominique Lamaison,Fiorenzo GaïTa,Mike Griffith,Thomas Arentz,Fernando Cruz,MéLèZe Hocini,Rukshen Weerasooriya,Pierre JaïS,Akihiko Nogami,Laurent Macle,Dipen C Shah,Dietrich Kalushe,Josef Kautzner,Jacques CléMenty,Morio Shoda,Angelo De Paola

doi:10.1161/01.cir.0000027564.55739.b1

Abstract

Ventricular fibrillation is the main mechanism of sudden cardiac death. The feasibility of eliminating recurrent episodes by catheter ablation has not been reported. Twenty-seven patients without known heart disease (13 men, 14 women, 41+/-14 years of age) were studied after being resuscitated from recurrent (10+/-12) episodes of primary idiopathic ventricular fibrillation; 23 had received a defibrillator. The first initiating beat of ventricular fibrillation had an identical electrocardiographic morphology and coupling interval (297+/-41 ms) to preceding isolated premature beats typically noted in the aftermath of resuscitation. These triggers were localized by mapping the earliest electrical activity and ablated by local radiofrequency delivery. Outcome was assessed by Holter and defibrillator memory interrogation. Premature beats were elicited from the Purkinje conducting system in 23 patients: from the left ventricular septum in 10, from the anterior right ventricle in 9, and from both in 4. The interval from the Purkinje potential to the following myocardial activation varied from 10 to 150 ms during premature beat but was 11+/-5 ms during sinus rhythm, indicating location at peripheral Purkinje arborization. The premature beats originated from the right ventricular outflow tract muscle in 4 patients. The accuracy of mapping was confirmed by acute elimination of premature beats during local radiofrequency delivery. During a follow-up of 24+/-28 months, 24 patients (89%) had no recurrence of ventricular fibrillation without drug. Primary idiopathic ventricular fibrillation is a syndrome characterized by dominant triggers from the distal Purkinje system. These sources can be eliminated by focal energy delivery.

Highlights

Ventricular fibrillation is the main mechanism of sudden cardiac death
Idiopathic Ventricular fibrillation (VF) in the absence of structural heart disease or surface electrocardiographic abnormalities accounts for 5% to 10% of survivors of out-ofhospital cardiac arrest.[1,2,3]
Mapping during VF has shown that fibrillation is perpetuated by reentrant or spiral waves, while recent data suggest the role of specific sources triggering the arrhythmia.[4,5]

Summary

Methods

Twenty-seven consecutive patients underwent attempted ablation of primary idiopathic VF in 6 centers. Six patients had a family history of sudden death (Table). Twenty-three had received a defibrillator but continued to suffer from recurrent VF or runs of polymorphic ventricular tachycardia (Figure 1), whereas 4 had no implanted defibrillator because they underwent early ablation with complete abolition of ventricular arrhythmia confirmed by prolonged inhospital monitoring and no longer warranted defibrillator insertion by the judgment of the treating clinicians. In 19 patients, VF as well as premature beats were temporally clustered within a few days (electrical storm), requiring multiple shocks, and reoccurred suddenly months or years later. The 8 remaining patients had persistent ventricular arrhythmias over long periods of time. A mean of 3.6Ϯ2 (median 4) antiarrhythmic drugs were unsuccessfully tried, including Vaughan-Williams class I drugs in 22, ␤-blockers in 19, amiodarone in 11, and verapamil in 16 (despite effectiveness of intravenous verapamil in 7)

Results

Discussion

Conclusion