Episodes Of Ventricular Tachycardia Research Articles

Electrical storm in a patient with Charcot-Marie-Tooth disease treated with radiofrequency ablation and subsequent serious complication of ICD implantation: a case report

Abstract Background Charcot-Marie-Tooth is the most common inherited neuromuscular disorder. Rarely, it can be associated with heart failure and various arrhythmic disturbances. This case illustrates the challenges of making decisions to prevent sudden cardiac death in a patient with Charcot-Marie-Tooth disease. Case Summary A 69-year-old male with a history of type 1A Charcot-Marie-Tooth disease was admitted due to repetitive runs of ventricular tachycardia. Twelve-lead ECG, echocardiography, selective coronary angiography, and cardiac magnetic resonance did not clarify the cause of the electrical storm. As conservative therapy was not successful, radiofrequency ablation was chosen to treat the electrical storm. After this procedure, ICD was implanted. The follow-up revealed severe perforation by the ventricular lead. An extraction was performed with no complications and a new lead immediately implanted. The patient remains asymptomatic. Three episodes of non-sustained ventricular tachycardia were recorded during the last follow-up. Discussion This case illustrates the challenges of making decisions to prevent sudden cardiac death in a patient with Charcot-Marie-Tooth disease after successful ablation for electrical storm. Due to a lack of evidence, atypical origin of arrhythmia and clinical presentation, we did not consider this as idiopathic arrhythmia and decided to implant an ICD, which was complicated by severe perforation by the lead. Specific recommendations for preventing sudden cardiac death in rare cardiac conditions, such as Charcot-Marie-Tooth disease, still need to be refined.

Abstract 4137919: Electrical Storm Caused by Chagasic Cardiomyopathy Successfully Treated with Ventricular Aneurysmectomy

Introduction: Chronic Chagasic cardiomyopathy (CCC) is a serious complication of Chagas disease that can manifest as LV dysfunction, ventricular aneurysms, and ventricular arrhythmias. Management of the electrical storm in CCC is challenging, especially when it is refractory to catheter ablation. Case Presentation: A 59-year-old woman from southern Peru presented to the ED with palpitations and dyspnea for 1 week. Physical exam was normal. ECG showed Q waves in III and AVF leads. TTE revealed an LVEF of 45% with an inferolateral LV aneurysm. Coronary angiography showed no lesions. CCC was suspected and serology was ordered, which was positive for T. cruzi . Cardiac MRI confirmed the presence of a 32x22mm basal inferolateral LV aneurysm. During hospitalization, she experienced 4 episodes of unstable monomorphic ventricular tachycardia (VT) within 24 hours, requiring defibrillation with 200J, vasopressor support, and invasive mechanical ventilation. The diagnosis of electrical storm secondary to CCC was proposed, for which amiodarone infusion was started until complete impregnation was achieved. Additionally, support was provided with IABP and specific antiparasitic treatment with benznidazole. Electrophysiology determined that the probable focus of the VT was situated at the level of the LV aneurysm. Therefore, ablation with endocardial-epicardial mapping was performed. However, the patient continued to experience recurrent episodes of VT. Consequently, in a multidisciplinary discussion, it was decided to perform a ventricular aneurysmectomy, which was successful. The patient's clinical progress was favorable, with initiation of GDMT and placement of a single-chamber ICD for secondary prevention. After one year of outpatient follow-up, the patient remains free of VT recurrences. Conclusion: Ventricular aneurysmectomy is a successful management approach for patients with CCC who present with electrical storm refractory to antiarrhythmic drugs and catheter ablation, and whose VT is believed to originate from the aneurysm. The diagnosis of CCC is highly arrhythmogenic and should be suspected at an early stage, given the patient's demographics and the presence of LV aneurysm in the absence of coronary artery disease.

Abstract 4119260: Anomalous Origin Of Left Circumflex Artery From Right Pulmonary Artery Resulting In Heart Failure: A Rare Vascular Steal Phenomenon

Background: Anomalous origin of coronary arteries from the pulmonary artery usually presents at a younger age. However, we encountered a case of a 62-year-old female with an anomalous origin of the left circumflex (LCx) artery from the right pulmonary artery. Case summary: A 62-year-old female presented with complaints of dyspnea and angina on exertion for 1 month and had paroxysmal nocturnal dyspnea for the last 4-5 days. She also had an episode of ventricular tachycardia which required DC cardioversion. She had diabetes mellitus type 2 and hypertension. ECG showed diffuse horizontal ST segment depression in precordial, and limb leads and ST segment elevation in aVR suggesting subendocardial ischemia. The echocardiogram showed hypokinesia in basal, mid-inferior and inferolateral segments and LVEF of 42%. There was a marked reduction in global longitudinal strain (average GLPS of -9.2%). Her coronary angiogram revealed extensive collaterals to the left circumflex artery (from the left anterior descending artery and right coronary artery). The left circumflex artery was arising from the pulmonary artery. Exact localization of origin was done by simultaneous contrast injections in the right pulmonary artery and LAD. The anomalous origin of LCx from the right pulmonary artery was hooked using a Tiger catheter. The patient was advised for surgical management; however, the patient has opted for medical therapy. Conclusion: The anomalous origin of coronary arteries from pulmonary arteries is usually detected in childhood e.g. ALCAPA and is associated with other congenital heart diseases. Anomalous origin of LCx from the right pulmonary artery is a rare variant. It can result in a steal phenomenon which may result in angina, heart failure and risk of sudden cardiac arrest.

Abstract 4123563: High Prevalence of Unrecognized Actionable Cardiac Arrhythmias in Patients with Moderate to Severe Chronic Obstructive Pulmonary Disease

Background: Patients with chronic obstructive pulmonary disease (COPD) are at high risk for developing arrhythmias due to hypoxemia, right heart failure and use of beta-agonists inhalers. Symptoms related to arrhythmias can often be masked or confounded by symptoms related to COPD exacerbation and remain undiagnosed. Objective: To identify the incidence of actionable arrhythmias in patients with no prior cardiology follow-up and moderate–severe COPD with continuous monitoring. Methods: An automatic referral for electrophysiology (EP) consult was generated in patients with moderate-severe COPD if they answered yes to one of the following: palpitations, dizziness, abnormal ECG, near syncope. Upon consultation with EP specialist, implantation of loop reorder was discussed (ILR) with the patient. Patients were then monitored for 12 months via remote monitoring. Actionable arrhythmia was defined the arrhythmia that correlated with symptoms triggered by the patient, necessitated adjustment of medications (including initiation of anticoagulation), catheter ablation and implantation of implantable cardiac defibrillator (ICD) or permanent pacemaker (PPM). Results: Out of 62 patients referred 22 (35.5%) agreed to undergo ILR implantation. Of the 22 (50.0% female, 62 ± 9.5 years) patients implanted with an ILR, 15 (68.2%) had an actionable arrhythmia after a mean follow-up of 2.7± .3 months. These included 14 symptomatic events requiring medication adjustment (10 atrial tachycardias, 4 ventricular events), 7 cases of atrial fibrillation (requiring initiation of anticoagulation in all cases and catheter ablation in 1), 1 case of sinus node dysfunction requiring pacemaker implantation, and 1 episodes of sustained ventricular tachycardia requiring ICD implantation. Conclusion: Continuous monitoring had high yield in diagnosing significant arrhythmic events in patients with moderate-severe COPD. Awareness should be raised about the high arrhythmic risk of this population and the role of continuous monitoring should be sought in larger studies.

Abstract 4122369: Beyond Closure: A Case Report on Coronary Steal Syndrome by Previously Embolized Internal Mammary Artery Side Branch

Background: Internal mammary artery (IMA) side branch flow diversion post- coronary artery bypass grafting (CABG) and its role in coronary steal syndrome remains controversial. However, evident association persists when substantial side branches stem from the IMA, possibly due to relatively lower peripheral resistance as compared to higher coronary resistance. Intervention has shown promise in ameliorating reversible ischemia in these cases. Recanalization of previously occluded side branch is rare and has only been reported within a 6 month period. We report a case of recanalization of a previously occluded side-branch after 4 years with recurrence of symptoms. Case: A 63-year-old male underwent CABG with LIMA-LAD in 2020 and coil embolization of LIMA side branch for symptomatic coronary steal syndrome (figure 1). Angina recurred 3 years later, leading to right coronary artery stent placement. He now presents with palpitations and dyspnea on exertion. Vital signs and physical exam was unremarkable. ECG showed a normal sinus rhythm with no signs of ischemia. A 24-hour Holter showed significant polymorphic ventricular ectopy and episodes of sustained ventricular tachycardia (arrhythmic burden 12.4%). Transthoracic echocardiogram showed an ejection fraction of 71% and slightly decreased left ventricular global longitudinal strain (-16.6%). Decision-making: A diagnostic cardiac catheterization was performed which showed patency of bypass and stent with no signs of occlusion or restenosis, rather revealing a permeable, previously occluded side-branch (figure 2A) and resurgent coronary steal phenomenon. Repeat coiling was performed, achieving complete cessation of flow (figure 2B) and evident increased flow to the LAD. Resolution of symptoms was observed and post-procedure Holter showed normal sinus rhythm with no arrhythmic changes. Conclusion: Recanalization of an IMA side branch after complete occlusion with multiple coils is rare, particularly beyond 6 months. This appears to be the first reported case of the phenomenon, occurring after 4 years. Administration of heparin for recent stent placement, continuation of oral antiplatelet therapy and distal coil location may have contributed to restoration of flow, despite the presence of intraluminal coils. Repeat coiling proved successful in relieving symptoms.

Abstract 4115542: Female patients with Andersen-Tawil Syndrome are more prone to develop cardiac arrest.

Background: Andersen-Tawil Syndrome (ATS) is an autosomal dominant disorder characterized by a triad of dysmorphic features, periodic muscular weakness, and ventricular arrhythmias. We presented a meta-analysis of cardiologic-affected ATS patients. Objective: This study sought to compare the characteristic features of ATS according to their gender with a special focus on the cardiologic anomalies. Methods: To enable a meta-analysis, we searched literature reviews of reported cases or cohort studies with ATS between 1994 and 2024. Cases were selected if they presented a cardiologic affection alone or combined with morphologic features, periodic paralysis, or both. A gender comparison was made using the available information. Each variable was calculated using the validated percentage. Numerical variables are expressed as mean or median and SD. Categorical variables are expressed as percentages. Student’s t-test was used for numerical variables. Categorical variables were analyzed using chi-square. The results were expressed as an odds ratio (OR) with a 95% confidence interval (CI). Values of p <0.05 were considered statistically significant. Results: The studied population consisted of 243 cardiologic-affected patients with ATS, 163 females, and 80 Males. Compared to males, females are less likely to present periodic paralysis (p = 0.03, OR = 0.54, 95% CI = 0.30-0.98). Analyzing cardiologic features, females had more syncope episodes than males (73% (n=52) vs. 22.4% (n=15). Only 45% of cases had a prolonged QTc. A longer QTc measure was reported in females (453 ± 52) compared to males (427 ± 55) (p = 0.004). Premature ventricular contractions (PVCs) were the most commonly reported arrhythmia, and bigeminy was the most common type of presentation. Polymorphic PVCs were more prevalent in females than males (p = 0.009, OR = 2.49, 95%CI = 1.24-4.99). Females reported more Ventricular tachycardias (VT) episodes than males, especially Bidirectional (p = 0.01, OR = 2.10, 95%CI = 1.17-3.78). Thirty-five patients had an episode of cardiac arrest, either non-fatal, fatal or in some cases non-fatal, followed by SCD after years. Females were more prone to develop cardiac arrest compared to males (n=29 vs. n=6, respectively; p = 0.03, OR = 2.66, 95%CI = 1.06-6.72). Conclusion: ATS females with cardiologic affection may require a closer follow-up due to the higher risk of developing life-threatening arrhythmias and cardiac arrest than males.

Abstract 4135194: Safety and Efficacy of Mechanical Circulatory Support during VT ablation

Introduction: Ventricular arrythmias are prevalent in patients with advanced heart failure and associated with increased mortality. Outcomes of electrophysiology ablation on patients requiring mechanical circulatory support (MCS) are not well described. We aimed to analyze the safety and efficacy of ventricular tachycardia (VT) ablation in patients requiring MCS at the Emory system. Methods: Patients were identified via retrospective chart review from October 2022 through August 2023. Patients who underwent VT ablation with the support of Impella, left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), and venoarterial extra-corpeal membrane oxygenation (VA ECMO), or any combination of these were included. Results: A total of 7 patients of average age 56 ± 10 years, predominantly male (85.7%), with cardiomyopathy of mean EF 18.6% +/- 8.5 (ischemic 71.4%) underwent MCS supported VT ablation. One patient had 2 separate VT ablation procedures for refractory VT. Of these 8 procedures, 4 utilized a single type of MCS (2 impella, 2 LVAD) while 4 used a second type of MCS in combination with an Impella (2 impella RP, 1 VA ECMO, 1 IABP). Success at time of ablation was present in 75% of cases. Average time of outpatient follow up was 82 ± 31 days. At time of follow up, 50% of patients remained free of VT or with a single VT episode not requiring implantable cardioverter-defibrillator (ICD) shock. One patient had gone on to undergo successful heart transplantation. Procedural complications were noted in one patient, who suffered cardioembolic cerebrovascular accident (CVA) 2 days post-op. Transthoracic echo (TTE) 5 days post-op revealed LV mural thrombus as likely etiology of CVA. Conclusion: While there are no clear guidelines directing the use of MCS during VT ablation, our single academic institution experience suggests safety and feasibility of its use to support select, high risk cases.

Mineralocorticoid receptor antagonist therapy in patients with ischemic heart failure and ventricular tachycardia: a comparative analysis of spironolactone vs. eplerenone

Abstract Background Mineralocorticoid receptor antagonists (MRAs) are a cornerstone of heart failure therapy and have been shown to reduce the incidence of sudden cardiac death. However, a direct comparison between spironolactone and eplerenone in patients who present ventricular tachycardia (VT) is lacking. Purpose This study aimed to compare the effect of spironolactone and eplerenone on VT recurrence in patients with ischemic heart disease (IHD) hospitalized for VT episodes. Methods Our data utilized a registry of 405 patients with IHD and HF, who were hospitalized for an episode of sustained VT and received MRA therapy. We performed propensity score matching based on age, hypertension, diabetes, history of acute myocardial infarction, left ventricular ejection fraction (LVEF) and presentation with incessant VT. The matched population included 200 patients, stratified into two equivalent groups. Cox regression analysis was performed to identify predictors of VT recurrence, with Kaplan-Meier curves facilitating time-to-event analyses. Results The median age was 69 years and the majority (91%) were male. One-third had an ICD, and 41 patients (20%) had CRT. The median LVEF was 30%, 23 patients (12%) presented with an electrical storm, while 18 (9%) had incessant VT. VT led to hemodynamic instability in 91 cases (46%). Ablation was performed in 47 patients (24%), while 1 required mechanical circulatory support. Ablation was performed in 47 patients (24%), while 1 required mechanical circulatory support. Patients were followed for at least a year and median follow-up time was 414 days. A total of 78 patients had VT recurrence and 117 patients died. Eplerenone use significantly reduced the risk of VT recurrence compared to spironolactone (HR: 0.59 [0.37-0.93], p=0.023). This effect was consistent in the multivariate model as well (p=0.007). Conclusions Eplerenone use may confer a greater protective effect against VT recurrence in patients with IHD and sustained VT. Further studies are required to confirm these preliminary findings.

Atrial rates during treated ventricular tachycardia in patients with implantable cardioverter defibrillators: clinical implications of a vagal sinus node response

Abstract Introduction Autonomic tone plays an important role in the genesis and sustenance of ventricular tachycardia (VT). Whilst sympathetic hyperactivity is an established driver of ventricular arrhythmias, sinus node response during VT varies broadly between patients, and can be paradoxical. Purpose We hypothesized that device-detected changes in sinus node rate could be an important surrogate of the autonomic response to VT, and may exert significant – and potentially modifiable – haemodynamic consequences independent of ventricular activity. Methods Device electrograms were analysed from consecutive patients with dual chamber implantable cardioverter defibrillators (ICDs) requiring anti-tachycardia pacing (ATP) or defibrillation for sustained monomorphic VT. Atrial rates were measured before VT onset (‘baseline’) and again at the point of detection by the device. Sinus node response was characterized as ‘stable’ (atrial rate remained within 10% of baseline), ‘sympathetic’ (atrial rate increased >10%) or ‘vagal’ (atrial rate decreased >10%). Patients who did not maintain ventriculoatrial dissociation or who presented in atrial tachyarrhythmia were excluded. Symptoms and electrical response to ICD therapies were recorded. Results 172 treated episodes of VT were included from 97 patients (median age: 69 years, 65% male, 31% ischaemic cardiomyopathy, median ventricular rate: 205bpm, median ejection fraction: 30%). Sinus node response was stable in 55%, sympathetic in 24% and vagal in 21%. A vagal response was associated with ATP-refractory VT (OR: 2.2 (1.1-4.8) p=0.03) and, when adjusting for ventricular rate, was independently associated with symptoms of presyncope or syncope (adjusted OR: 6 (2.7-13.7), p<0.0001). Conclusions This preliminary analysis suggests that a vagal sinus node response during VT is associated with adverse outcomes in ICD patients. Vagolytic therapy has recently been demonstrated to improve haemodynamic tolerance during VT ablation; whether supportive atrial pacing during VT could mitigate symptoms and potentiate arrhythmia termination in ICD patients warrants further exploration. Figure 1: Change in sinus node rate during sustained monomorphic ventricular tachycardia in patients with dual chamber ICDs, stratified by the occurrence of presyncopal symptoms or syncopeFigure 1

Targeting ventricular tachycardia originating from the anterolateral papillary muscle with stereotactic body radioablation therapy

Abstract Background Ventricular Tachycardia (VT) is prevalent in the setting of non-ischaemic cardiomyopathy (NICM), a heterogeneous group of conditions characterized by myocardial dysfunction in the absence of coronary artery disease. Challenges of catheter ablation to treat VT in NICM patients are well known, and recurrence rates can be as high as 58%. Stereotactic body radioablation therapy (SBRT) involves precise delivery of radiation to arrhythmogenic substrates, and represents a novel treatment to reduce recurrent implantable cardioverter defibrillator (ICD) therapies in patients with refractory VT. Though SBRT has shown preliminary effectiveness in reducing VT episodes, its effectiveness in NICM patients has not been widely evaluated. Purpose To evaluate SBRT effectiveness in NICM patients with scars at the basal anterolateral papillary muscle at a tertiary care center between November-December 2022. Methods Eligible patients had their VT substrate mapped using a single-use ECGI vest and a 4D-CT simulation scan. In addition, MRI scans were used to aid anatomical identification of the anterolateral papillary muscle which could not be seen on the non-contrast diagnostic CTs. SBRT was delivered in a single fraction of 25 Gy under image guidance. Effectiveness of the treatment was evaluated as changes in frequencies of total antitachycardia pacing (ATP) and ICD shock episodes from 6 months pre-, and within to 3, 6, and 12 months follow up post SBRT. Results Participants were 3 males with NICM, aged 56, 60, and 73 with previous dual chamber ICD implantation, 2 of whom had a history of VT ablation/ VT storm and paroxysmal atrial fibrillation. All participants had basal lateral scar, and were receiving beta blockers, mexiletine, and amiodarone with refractory VT before SBRT treatment. Prior to SBRT, ICD device interrogation showed a total of 119 (77, 7, and 35 in patients 1-3 respectively) ATPs, and 27 (10, 1, and 16 in patients 1-3 respectively) ICD shocks delivered. At 12 month follow-up, none of the participants experienced any episodes of ATP or ICD shock. Ejection fraction remained consistent pre-post SBRT. Conclusion SBRT showed remarkable success in reducing ATP and ICD shock episodes, facilitating uncomplicated 1 year follow-up in 3 male patients with NICM and VT from the anterolateral papillary muscle.

Post-Exercise Syncope in a Previously Healthy 67-Year-Old Man: The Bezold–Jarisch Reflex and the Role of Autonomic Nervous System Dysfunction

A 67-year-old man started treatment due to frequent asymptomatic premature ventricular complexes (PVCs) accidentally being registered during a preventive examination by a specialist, because of which he was referred to cardiologist. During the initial 24-hour (h) ECG monitoring, 4.5% PVCs and one episode of asymptomatic non-sustained ventricular tachycardia (NSVT) with three PVCs in row, at a frequency of 150 beats per minute (bpm), were detected. After the introduction of beta blockers into therapy, a lower number of PVCs, without NSVT, were recorded in the control 24 h Holter ECG, while transthoracic echocardiography (TTE) showed normal left ventricular (LV) systolic function without cardiomyopathy. So, an exercise test was indicated, and it was interrupted in the third minute at 120 beats per minute (bpm) due to fatigue and pain in the hips, without malignant arrhythmias, angina or dyspneic complaints. During the rest period, a significant inferolateral depression of the ST junction was observed, which recovered in the ninth minute. Immediately after the ECG monitoring stopped, the patient lost consciousness; his pulse was not palpable, but breathing was audible, so cardiac massage was started. After he had regained consciousness, the ECG showed alternating sinus and junctional rhythm with the lowest frequency of 33 bpm, which was accompanied by marked hypotension (80/50 mmHg). The patient was immediately hospitalized; coronary angiography and repeated TTE were completely normal, while continuous ECG monitoring did not confirm malignant rhythm disorders or asystole. It was concluded that it was vasovagal syncope (VVS), most likely caused by the Bezold–Jarisch reflex (BJR).

"Hot phase" clinical presentation of biventricular arrhythmogenic cardiomyopathy: when the perfect electrical storm spontaneously stops.

An 18-year-old male presented with syncope during a training break. Post-syncope, he developed effort dyspnea, which he associated with the Pfizer-BioNTech COVID-19 vaccine received a week earlier. Electrocardiogram showed T inversion in V1-V3, III, and aVF, while 24-hour Holter monitoring revealed frequent ventricular premature beats. A transthoracic echocardiogram showed severe biventricular dilation and mild left ventricular (LV) dysfunction. Cardiac magnetic resonance (CMR) imaging confirmed these findings, showing moderate right ventricular (RV) systolic dysfunction with akinesia of the inferior and inferolateral walls. T2 hypersignal in the middle segment of the inferior inferior interventricular septum suggested myocardial edema. Extensive transmural late gadolinium enhancement was noted in the RV and LV walls. An implantable loop recorder was implanted. Three months later, the patient was admitted with palpitations, fever, and a positive SARS-CoV-2 test. Sustained ventricular tachycardia (VT) episodes were documented and managed with amiodarone and β-blockers. Follow-up CMR showed a slight improvement in LV ejection fraction and resolution of edema. A single-chamber implantable cardioverter-defibrillator (ICD) was implanted. Genetic testing for arrhythmogenic RV cardiomyopathy (ARVC) was negative, and family screening was normal. Two years later, pre-syncope episodes occurred, and ICD interrogation revealed nonsustained VT. The patient is awaiting VT ablation. This case highlights the diagnostic and therapeutic challenges of ARVC, particularly in differentiating it from myocarditis. The "hot-phase" presentation, vaccine association, and subsequent SARS-CoV-2 infection added complexity. CMR was crucial for diagnosis, and VT management required a combination of medical therapy and invasive procedures.

Use of Esmolol to treat resistant electrical storm in a patient with decompensated heart failure

BackgroundVentricular tachycardia storm is a syndrome defined by the presence of at least three episodes of ventricular tachycardia over a 24-h period, requiring termination by intervention. Standard therapy consists initially of using intravenous betablockers (if left ventricular ejection fraction is preserved) and Amiodarone, in addition to intravenous Lidocaine (in case of ischemic etiology) and light sedation. In the present case, a ventricular tachycardia storm episode is terminated by Esmolol, a particular intravenous betablocker, despite acute decompensated heart failure.Case presentationWe report the case of an 89-year-old patient presenting for a ventricular tachycardia storm and acute heart failure with reduced left ventricle ejection fraction of coronary ischemic origin that persisted despite coronary revascularization, oral betablocker, intravenous Amiodarone and Lidocaine, light sedation, and multiple electrical cardioversion. Emergency catheter ablation was not feasible due to meteorological conditions. We decided to use an intravenous betablocker despite the presence of acute heart failure. We favored use of intravenous Esmolol over other intravenous betablockers due to its short half-life and thus his rapid elimination, a unique characteristic for Esmolol. Intravenous Esmolol has successfully terminated the ventricular tachycardia without causing cardiogenic shock.ConclusionsIntravenous Esmolol can be used safely in patients with acute decompensated heart failure to terminate an electrical storm after failure of other measures. Close monitoring of the patient remains essential.

Expect the unexpected: fulminant myocardial cytotoxic Injury from Trabectedin

BackgroundTrabectedin (Tbt) is an alkylating agent prescribed for soft tissue sarcomas after treatment failure of first line agents. While cardiomyopathy can occur with Tbt treatment after anthracycline exposure, Tbt-induced fulminant myocardial cytotoxic injury in the setting of other systemic cytotoxicity associated with Tbt has not been reported.Case presentation51-year-old female with hypertension, hyperlipidemia, metastatic leiomyosarcoma with progression of disease despite several lines of chemotherapy including doxorubicin-based therapy was started on Trabectedin (Tbt) 5 days prior to presentation with symptoms of fever, myalgias, arthralgias, and palpitations. She was admitted for management of rhabdomyolysis, acute kidney and liver injuries which were reportedly known to be associated with Tbt treatment. A baseline electrocardiogram (ECG) revealed sinus tachycardia with non-specific T-wave changes, and a transthoracic echocardiogram (TTE) was unremarkable. However, on day 3 of hospitalization, an episode of asymptomatic sustained monomorphic ventricular tachycardia with a heart rate of 150 beats per minute was captured on telemetry. A 12-lead ECG revealed new septal T-wave inversions. Labs revealed rising hs-TnI levels (peak at 37,933ng/L) and serum markers suggested multi-organ failure. Steroids were initiated given its role in treating multi-organ Tbt-induced toxicity. A cardiac MRI to rule out myocarditis and left heart catheterization to rule out obstructive coronary artery disease were forgone due to acute renal failure. A right heart catheterization with an endomyocardial biopsy was performed revealing normal cardiac filling pressures and indices. Pathology showed cytoplasmic vacuoles indicating drug-induced myocardial cytotoxicity. Serial echocardiograms revealed preserved biventricular function. The patient’s clinical condition deteriorated with multi-organ failure despite maximal supportive care in the intensive care unit. She ultimately passed away, and an autopsy was declined.ConclusionThis is the first reported case of fulminant myocardial injury after initiation of Tbt with histologic evidence of drug-induced myocardial cytotoxicity. While it is unclear if anthracyclines potentiate Tbt cytotoxic injury as in this case, it is plausible; and that Tbt-induced cardiotoxicity ranges from subclinical to fulminant. Given increasing use of Tbt in refractory high-grade sarcomas, raising awareness of its toxicity profile will improve early detection and outcomes.

Amiodarone or Implantable Cardioverter-Defibrillator in Chagas Cardiomyopathy

Over 10 000 people with Chagas disease experience sudden cardiac death (SCD) annually, mostly caused by ventricular fibrillation. Amiodarone hydrochloride and the implantable cardioverter-defibrillator (ICD) have been empirically used to prevent SCD in patients with chronic Chagas cardiomyopathy. To test the hypothesis that ICD is more effective than amiodarone therapy for primary prevention of all-cause mortality in patients with chronic Chagas cardiomyopathy and moderate to high mortality risk, assessed by the Rassi score. CHAGASICS is an open-label, randomized clinical trial. The study enrolled patients from 13 centers in Brazil from May 30, 2014, to August 13, 2021, with the last follow-up November 8, 2021. Patients with serological findings positive for Chagas disease, a Rassi risk score of at least 10 points (intermediate to high risk), and at least 1 episode of nonsustained ventricular tachycardia were eligible to participate. Data were analyzed from May 3, 2022, to June 16, 2023. Patients were randomized 1:1 to receive ICD or amiodarone (with a loading dose of 600 mg after randomization). The primary outcome was all-cause mortality, and secondary outcomes included SCD, hospitalization for heart failure, and necessity of a pacemaker during the entire follow-up. The study was stopped prematurely for administrative reasons, with 323 patients randomized (166 in the amiodarone group and 157 in the ICD group), rather than the intended 1100 patients. Analysis was by intention to treat at a median follow-up of 3.6 (IQR, 1.8-4.4) years. Mean (SD) age was 57.4 (9.8) years, 185 patients (57.3%) were male, and the mean (SD) left ventricular ejection fraction was 37.0% (11.6%). There were 60 deaths (38.2%) in the ICD arm and 64 (38.6%) in the amiodarone group (hazard ratio [HR], 0.86 [95% CI, 0.60-1.22]; P = .40). The rates of SCD (6 [3.8%] vs 23 [13.9%]; HR, 0.25 [95% CI, 0.10-0.61]; P = .001), bradycardia requiring pacing (3 [1.9%] vs 27 [16.3%]; HR, 0.10 [95% CI, 0.03-0.34]; P < .001), and heart failure hospitalization (14 [8.9%] vs 28 [16.9%]; HR, 0.46 [95% CI, 0.24-0.87]; P = .01) were lower in the ICD group compared with the amiodarone arm. In patients with chronic Chagas cardiomyopathy at moderate to high risk of mortality, ICD did not reduce the risk of all-cause mortality. However, ICD significantly reduced the risk of SCD, pacing need, and heart failure hospitalization compared with amiodarone therapy. Further studies are warranted to confirm the evidence generated by this trial. ClinicalTrials.gov Identifier: NCT01722942.

Implementing stereotactic arrhythmia radioablation with STOPSTORM.eu consortium support: intermediate results of aprospective Israeli single-institutional trial.

Ventricular tachycardia (VT) is alife-threatening arrhythmia originating from the heart's ventricles. Traditional treatments include antiarrhythmic medications, implantable cardioverter-defibrillators (ICDs), and catheter ablation. Stereotactic body radiation therapy (SBRT) targeting the arrhythmogenic focus in the left ventricle-stereotactic arrhythmia radioablation (STAR)-is an emerging treatment and may offer apotential solution for patients with refractory VT. We designed an interventional prospective clinical trial in Israel aligned with the STOPSTORM.eu consortium's benchmarks, recommendations, and directives to assess the safety and efficacy of STAR in patients with refractory VT. Our phaseI/II single-institutional trial was approved by the Ministry of Health of Israel for 10patients, initially assessing safety in the first 3patients. We included patients with ICDs experiencing symptomatic monomorphic VT after an inadequate response to previous therapies. The primary endpoints were treatment-related serious adverse events and areduction in VT burden as assessed by ICD interrogation. Secondary outcomes included areduction in antiarrhythmic medications and changes in quality of life. From August 2023 to August 2024, 3patients underwent STAR treatment. The prescription dose was asingle fraction of 25 Gy. Planning target volumes were 47.8, 49.7, and 91.8 cc, and treatment was successfully delivered with no grade3 or higher adverse events reported. Over afollow-up period of 12months for the first patient and 8months for the second one, no VT events were recorded after treatment. The third patient died from progressive heart failure 3months after treatment. Left ventricular ejection fraction remained stable, and no significant radiation-induced inflammatory changes were noted. The initial results of this trial suggest that STAR can reduce VT episodes in patients with refractory VT without severe adverse effects. The study highlights the importance of international collaboration and standardization in pioneering new treatments. Further follow-up and additional patient data will be necessary to confirm these findings and evaluate long-term outcomes, including potential adjustments to antiarrhythmic medication regimens.

1346: Impact of cardiac SABR on ventricular tachycardia episodes: single institution experience.

1346: Impact of cardiac SABR on ventricular tachycardia episodes: single institution experience.

Prognostic value of non-invasive programmed ventricular stimulation after VT ablation to predict VT recurrences.

The prognostic value of (non)-invasive programmed ventricular stimulation (NIPS) to predict recurrences of ventricular tachycardia (VT) is under discussion. Optimal endpoints of VT ablation are not well defined, and optimal timepoint of NIPS is unknown. The goal of this study was to evaluate the ability of programmed ventricular stimulation at the end of the VT ablation procedure (PVS) and NIPS after VT ablation to identify patients at high risk for VT recurrence. Between January 2016 and February 2022, consecutive patients with VT and structural heart disease undergoing first VT ablation and consecutive NIPS were included. In total, 138 patients were included. All patients underwent NIPS through their implanted ICDs after a median of 3 (1-5) days after ablation (at least 2 drive cycle lengths (500 and 400ms) and up to four right ventricular extrastimuli until refractoriness). Clinical VT was defined by comparison with 12-lead electrocardiograms and stored ICD electrograms from spontaneous VT episodes. Patients were followed for a median of 37 (13-61) months. Of the 138 patients, 104 were non-inducible (75%), 27 were inducible for non-clinical VTs (20%), and 7 for clinical VT (5%). In 107 patients (78%), concordant results of PVS and NIPS were observed. After 37 ± 20months, the recurrence rate for any ventricular arrhythmia was 40% (normal NIPS 29% vs. inducible VT during NIPS 66%; log-rank p = 0.001) and for clinical VT was 3% (normal NIPS 1% vs. inducible VT during NIPS 9%; log-rank p = 0.045). Positive predictive value (PPV) and negative predictive value (NPV) of NIPS were higher compared to PVS (PPV: 65% vs. 46% and NPV: 68% vs. 61%). NIPS revealed the highest NPV among patients with ICM and LVEF > 35%. Patients with inducible VT during NIPS had the highest VT recurrences and overall mortality. Patients with both negative PVS and NIPS had the lowest any VT recurrence rates with 32%. Early re-ablation of patients with recurrent VTs during index hospitalization was feasible but did not reveal better long-term VT-free survival. In patients after VT ablation and structural heart disease, NIPS is superior to post-ablation PVS to stratify the risk of VT recurrences. The PPV and NPV of NIPS at day 3 were superior compared to PVS at the end of the procedure to predict recurrent VT, especially in patients with ICM.

Early experience with mechanical hemodynamic support for catheter ablation of malignant ventricular tachycardia

Objective: To explore the role of mechanical hemodynamic support (MHS) in mapping and catheter ablation of patients with hemodynamically unstable ventricular tachycardia (VT), report single-center experience in a cohort of consecutive patients receiving VT ablation during MHS therapy, and provide evidence-based medical evidence for clinical practice. Methods: This was a retrospective cohort study. Patients with hemodynamically unstable VT who underwent catheter ablation with MHS at Beijing Anzhen Hospital, Capital Medical University between August 2021 and December 2023 were included. Patients were divided into rescue group and preventive group according to the purpose of treatment. Their demographic data, periprocedural details, and clinical outcomes were collected and analyzed. Results: A total of 15 patients with hemodynamically unstable VT were included (8 patients in the rescue group and 7 patients in the preventive group). The acute procedure was successful in all patients. One patient in the rescue group had surgical left ventricular assist device (LVAD) implantation, remaining 14 patients received extracorporeal membrane oxygenation (ECMO) for circulation support. ECMO decannulation was performed in 12 patients due to clinical and hemodynamic stability, of which 6 patients were decannulation immediately after surgery and the remaining patients were decannulation at 2.0 (2.5) d after surgery. Two patients in the rescue group died during the index admission due to refractory heart failure and cerebral hemorrhage. During a median follow-up of 30 d (1 d to 12 months), one patient with LVAD had one episode of ventricular fibrillation at 6 months after discharge, and no further episodes of ventricular fibrillation and/or VT occurred after treatment with antiarrhythmic drugs. No malignant ventricular arrhythmia occurred in the remaining 12 patients who were followed up. Conclusions: MHS contributes to the successful completion of mapping and catheter ablation in patients with hemodynamically unstable VT, providing desirable hemodynamic status for emergency and elective conditions.

EASI monitoring in ventricular tachycardia, an alternative to conventional electrocardiography?

Abstract Background 12-lead electrocardiogram (ECG) is the gold standard for detecting ventricular arrhythmias. In cardiac critical care units (UCC), monitoring systems are used to detect transient events such as arrhythmias or ST-segment acute changes. The discomfort caused in the patient by the need for 10 electrodes to obtain the 12 leads continuously means that complete monitoring is not routine. The EASI monitoring system, based on vector electrocardiography, is an alternative that uses only 5 electrodes (4 thoracic and 1 ground) and theoretically allows obtaining a complete standard ECG. Objectives The main endpoint of this study was to evaluate the diagnostic accuracy of the EASI monitoring system in patients with ventricular tachycardia (VT), compared with conventional ECG. Methods Seven cases of patients admitted to the CCU due to episodes of VT are presented. The patients were monitored with the EASI system upon arrival, and the conventional ECG and the one derived from the EASI system were taken simultaneously for VT events for comparison. The 4 electrodes of the EASI system were placed, as recommended, on the sternal manubrium (S), lower sternum at the level of the 5th intercostal space (E), at the level of the 5th intercostal space, and on the right and left midclavicular lines (I and A). Results Analysing case by case, the axis of the tachycardia was similar in 5 patients, being able to assess the origin of the tachycardia in them. In 2 patients it was different. These cases of patients that differ, one episode has its origin in the right ventricular outflow tract (endocardial) and the other in the area of the left ventricular summit (epicardial). Two patients with different tachycardias and no cardiac characteristics in common. Figure 1. Conclusions EASI monitoring is a feasible alternative for monitoring patients in the CCU, which could give us reliable information (compared with standard ECG) with limitations in some cases in which the cardiac axis differs. For patients admitted for arrhythmic events, a better characterization of the differences would be interesting in order to optimize its use.