Management Of Ventricular Arrhythmias Research Articles

Postmortem genetic analysis following sudden cardiac death : Background, approach, and future

Sudden cardiac death (SCD) is defined as an unexpected, nontraumatic death with apossible cardiac or unknown cause. The lowest incidence is observed in infancy and childhood (1per 100,000), and the incidence is approximately 50per 100,000 in the middle-aged population, reaching aplateau around the age of 80 (200 per100,000). While most SCD cases occur in older people with coronary artery disease, there is apredominance of monogenetic and polygenetic diseases in the young. Postmortem genetic analysis (molecular autopsy) using next-generation sequencing reveals adefinite pathogenic genetic alteration, which can explain SCD of young patients in near 20% of the cases. Hence, postmortem genetic analysis has become an important tool to unravel the inheritable cause of death. Furthermore, early identification of apathogenic genetic sequence variant in the deceased is crucial to reduce risk in relatives due to preventive personalized measures. Postmortem genetic analysis forms together with the clinical assessment the basis for early identification of at-risk relatives. Anew guideline for the management of ventricular arrhythmias and prevention of sudden death was recently published by the European Society of Cardiology. The new recommendations give genetic testing, also in deceased patients amuch higher priority reflecting increasing relevance of genetic testing for diagnostic evaluation, risk stratification and prevention.

Evaluation and Management of Sudden Death Risk in Repaired Tetralogy of Fallot.

Although substantial progress has been made to prevent sudden cardiac death in repaired tetralogy of Fallot patients, ventricular arrhythmia and sudden death continue to be major causes of morbidity and mortality in these patients. Greater survival in contemporary cohorts has been attributed to enhanced surgical techniques, more effective management of heart failure, and increased efforts in risk stratification and management of ventricular arrhythmias. More recently, our understanding of predictive risk factors has evolved into personalized risk prediction tools that rely on comprehensive demographic, imaging, functional, and electrophysiological data. However, the universal applicability of these different scoring systems is limited due to differences between study cohorts, types of anatomic repair, imaging modalities, and disease complexity. Noninvasive risk stratification is critical to identify those who may derive benefit from catheter ablation or cardioverter defibrillator implantation for primary prevention. Ultimately, assessment and risk stratification by a multidisciplinary team is crucial to analyze the various complex factors for every individual patient and discuss further options with patients and their families.

Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 2: Ventricular and bradyarrhythmias.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. This is the second article in a 2-part series reviewing the pathophysiology and treatment considerations for arrhythmia. Part 1 of the series discussed aspects related to treating atrial arrhythmias. Here in part 2, the pathophysiology of ventricular arrhythmias and bradyarrhythmias and current evidence on treatment approaches are reviewed. Ventricular arrhythmias can arise suddenly and are a common cause of sudden cardiac death. Several antiarrhythmics may be effective in management of ventricular arrhythmias, but there is robust evidence to support the use of only a few of these agents, and that evidence was largely derived from trials involving patients with out-of-hospital cardiac arrest. Bradyarrhythmias range from asymptomatic mild prolongation of nodal conduction to severe conduction delays and impending cardiac arrest. Vasopressors, chronotropes, and pacing strategies require careful attention and titration to minimize adverse effects and patient harm. Ventricular arrhythmias and bradyarrhythmias can be consequential and require acute intervention. As experts in pharmacotherapy, acute care pharmacists can participate in providing high-level intervention by aiding in diagnostic workup and medication selection.

Ventricular tachycardia as presenting arrhythmia as a determinant of appropriate implantable cardioverter-defibrillator therapy in secondary prevention

Abstract Funding Acknowledgements Type of funding sources: None. Background Sudden cardiac death (SCD) is a leading cause of death. The implantable cardioverter-defibrillator (ICD) is an established therapy to prevent SCD in patients with prior ventricular tachycardia (VT) or ventricular fibrillation (VF). Determination of patient characteristics related to ICD therapies may provide targets for more intensive monitoring or management of ventricular arrhythmias. Therefore, we aimed to find determinants of appropriate ICD therapy. Methods In this retrospective, single-centre study, 223 consecutive secondary prevention ICD recipients were included. Data was obtained on medical history, laboratory measurements, electrocardiography and echocardiography. The primary outcome was appropriate ICD therapy, which included shock and antitachycardia pacing (ATP) given for VF or VT. Backward stepwise Cox regression analysis was performed to find determinants of appropriate therapy. Results The median age of the study population was 65.3 years (interquartile range (IQR) 55.4 – 72.0 years). 188 (84.3%) patients were male. 153 (68.6%) patients had ischemic heart disease. During a median follow-up duration of 6.00 years (interquartile range (IQR) 4.85 – 7.70 years), appropriate ICD therapy occurred in 89 (39.9%) patients, appropriate ICD shock in 65 (29.1%) patients, death in 55 (24.7%), inappropriate shock in 11 (4.9%) and device-related complications in 18 (8.1%). VT as index arrhythmia, QRS fragmentation and diminished right ventricular function were determinants of appropriate device therapy. Interestingly, whereas the majority of patients (141 (63.2%)) had an ICD implanted for initial presentation with VF, the first occurrence of appropriate therapy during follow-up was for monomorphic VT in the majority of patients (84 (94.4%)). Conclusion In patients with a secondary prevention ICD indication, VT as presenting arrhythmia is a determinant of appropriate ICD therapy during follow-up. Most ICD therapies during follow-up were applied for monomorphic VT.

Stereotactic Arrhythmia Radioablation Treatment of Ventricular Tachycardia: Current Technology and Evolving Indications

Ventricular tachycardia in patients with structural heart disease is a significant cause of morbidity and mortality. According to current guidelines, cardioverter defibrillator implantation, antiarrhythmic drugs, and catheter ablation are established therapies in the management of ventricular arrhythmias but their efficacy is limited in some cases. Sustained ventricular tachycardia can be terminated by cardioverter-defibrillator therapies although shocks in particular have been demonstrated to increase mortality and worsen patients' quality of life. Antiarrhythmic drugs have important side effects and relatively low efficacy, while catheter ablation, even if it is actually an established treatment, is an invasive procedure with intrinsic procedural risks and is frequently affected by patients' hemodynamic instability. Stereotactic arrhythmia radioablation for ventricular arrhythmias was developed as bail-out therapy in patients unresponsive to traditional treatments. Radiotherapy has been mainly applied in the oncological field, but new current perspectives have developed in the field of ventricular arrhythmias. Stereotactic arrhythmia radioablation provides an alternative non-invasive and painless therapeutic strategy for the treatment of previously detected cardiac arrhythmic substrate by three-dimensional intracardiac mapping or different tools. Since preliminary experiences have been reported, several retrospective studies, registries, and case reports have been published in the literature. Although, for now, stereotactic arrhythmia radioablation is considered an alternative palliative treatment for patients with refractory ventricular tachycardia and no other therapeutic options, this research field is currently extremely promising.

Advancements in management of ventricular arrhythmias

Advancements in management of ventricular arrhythmias

957 EMERGING FROM THE DARKNESS. SUDDEN CARDIAC DEATH IN CARDIAC AMYLOIDOSIS

Abstract Cardiac amyloidosis (CA) manifests as infiltrative cardiomyopathy with a hypertrophic pattern, usually presenting with heart failure with preserved ejection fraction (HFpEF). In addition, degenerative valvular heart disease, particularly severe aortic stenosis, is commonly seen in patients with CA. However, amyloid fibril deposition may also infiltrate the conduction system and promote the development of electrical disorders, including ventricular tachyarrhythmias (VT), atrio-ventricular block, or acute electromechanical dissociation (EMD). These manifestations can increase the risk of sudden cardiac death (SCD). This review summarizes the pathophysiological mechanisms and risk factors for sudden cardiac death in cardiac amyloidosis and focuses on the major current concerns regarding medical and device management in this challenging scenario. Heart involvement is the major determinant of survival in patient with amyloidosis and a “sudden death” occurs in approximately two-thirds of patients with cardiac amyloidosis. Moreover, the AL amyloid fibrils are shown to be highly cytotoxic to the ventricular myocardial, explaining why ventricular arrhythmias appear more frequently in AL over ATTR. Proposed mechanisms driving electrophysiological manifestations of CA involve intramural coronaries, microvascular ischemia, or patchy myocardium infiltration of amyloid fibrils, causing the development of anatomical re-entrant circuits responsible for ventricular arrhythmia. The prevalence of non-sustained ventricular tachycardia (NSVT) in AL amyloidosis ranges from 5 to 27% with routine monitoring and 100% during the stem cell transplant period. The guidelines don't provide specific indications regarding insertion of implantabile cardioverter defibrillator (ICD) and they don't clarify whether some patients subtypes can benefit from them. Amyloid infiltration into the conduction system enhances the genesis of rhythm disturbances, including fatal ventricular arrhythmias and SCD. Current pharmacological anti-arrhythmic therapies are poorly tolerated in CA, and there are no robust recommendations on the management of ventricular arrhythmias in this subset of patients. Furthermore, the benefit of ICD implantation is highly variable according to the different clinical stages of the disease. Therefore, further studies are needed to create a standardized diagnostic algorithm and appropriate treatment strategy for this special population.

2022 ESC Guidelines for the management of ventricular arrhythmias and sudden cardiac death: an important focus on a multidisciplinary approach to a tailored diagnostic and therapeutic work-up

2022 ESC Guidelines for the management of ventricular arrhythmias and sudden cardiac death: an important focus on a multidisciplinary approach to a tailored diagnostic and therapeutic work-up

Adjunctive Therapies for Ventricular Arrhythmia Management

The autonomic nervous system plays an integral role in the pathophysiology of ventricular arrhythmias. In the modern era, several therapeutic interventions are available to the clinician for bedside and procedural/surgical management, and there are many ways in which modulation of the autonomic nervous system can provide life-saving benefit. This review discusses some of the current treatment options, the supporting evidence, and also introduce some of the emerging therapies in this expanding field of electrophysiology.

Evaluation and Catheter Ablation of Ventricular Arrhythmias in Cardiac Sarcoidosis.

Ventricular arrhythmias are a common clinical manifestation in patients with cardiac sarcoidosis (CS) and other arrhythmogenic inflammatory cardiomyopathies (AIC). The management of sustained ventricular arrhythmias in these patients presents unique challenges. Current therapies include immunosuppressive, antiarrhythmic agents, and catheter ablation. Significant progress has been made in deciphering the importance of patient selection for ablation, systematic preablation evaluation, and optimal ablation timing, as well as ablation approaches and techniques. In this overview, we discuss the evaluation and management of ventricular arrhythmias in patients with CS, focusing on catheter ablation, which has evolved into an effective approach in reducing the burden of ventricular arrhythmias in these patients in the context of multifaceted treatment along with medical therapies.

Effect of C-type natriuretic peptide and amiodarone in Chinese patients with arrhythmia

Purpose: To compare the effect of C-type natriuretic peptide and amiodarone in Chinese patients with arrhythmia. 
 Method: Chinese men and women aged 18 to 65 years with premature ventricular complexes (PVCs), were administered C-type natriuretic peptide (CNP) - test group or amiodarone (study group) in ratio of 1:1 for 96 h. Patients in CNP group received infusion of synthetic human CNP (10 pmol/kg/min) for an initial 2 h, and then for 30 min every day until discharge. Patients in amiodarone group received initial dose of 1000 mg over the first 24 h. Change in PVCs from baseline was the primary efficacy endpoint. Secondary efficacy endpoint includes: change in PVCs-related symptom scores from baseline, change in ejection fraction of left ventricle (LV), end‑diastolic diameter of LV, and cardiac events as composite outcome (CCE). The effect of both treatments on hemodynamic and electrocardiography parameters, and safety were evaluated. Data from 200 patients were analyzed. 
 Results: The CNP showed significantly greater decrease in the number of PVCs when compared to amiodarone (p < 0.005). Moreover, CNP was superior in alleviating PVCs- related symptoms when compared to amiodarone (p < 0.005). A similar trend of favorable effect of CNP was observed for other endpoints. 
 Conclusion: The C-type natriuretic peptide offers significantly greater benefits of suppressing PVCs and related symptoms, and demonstrates significantly greater improvement of cardiac function and clinical outcome. Thus, CNP can be considered for further investigation as a suitable alternative in the management of ventricular arrhythmia with PVC among Chinese patients.

Hybrid-Approach Ablation in Drug-Refractory Arrhythmogenic Right Ventricular Cardiomyopathy

Management of ventricular arrhythmias (VAs) beyond implantable cardioverter-defibrillator positioning in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is challenging. Catheter ablation of the ventricular substrate often requires a combination of endocardial and epicardial approaches, with disappointing outcomes due to the progressive nature of the disease. We report the Universitair Ziekenhuis Brussel experience through a case series of 16 patients with drug-refractory ARVC, who have undergone endocardial and/or epicardial catheter ablation of VAs with a thoracoscopic hybrid-approach. After a mean follow-up time of 5.16 years (SD 2.9 years) from the first hybrid-approach ablation, VA recurrence was observed in 5 patients (31.25%): among these, patients 4 patients (80%) received a previous ablation and 1 of 11 patients (9.09%) who had a hybrid ablation as first approach had a VA recurrence (80% vs 9.09%; log-rank p=0.04). Despite the recurrence rate of arrhythmic events, all patients had a significant reduction in the arrhythmic burden after ablation, with a mean of 4.65 years (SD 2.9 years) of freedom from clinically significant arrhythmias, defined as symptomatic VAs or implantable cardioverter-defibrillator-delivered therapies. In conclusion, our case series confirms that management of VAs in patients with ARVC is difficult because patients do not always respond to antiarrhythmic medications and can require multiple invasive procedures. A multidisciplinary approach involving cardiologists, cardiac surgeons, and cardiac electrophysiologists, together with recent cardiac mapping techniques and ablation tools, might mitigate these difficulties and improve outcomes.

LIDOCAINE IN VENTRICULAR TACHYCARDIA WITH HEMODYNAMICALLY UNSTABLE WHO REFUSE CARDIOVERSION, IS IT THE FIRST CHOICE OR NOT?

Sudden cardiac death (SCD) is a vital public health issue, accountable for almost 50% of all cardiovascular deaths. In the last three decades, SCD was the leading cause for almost 230000 to 350000 deaths per annum in the United States. Ventricular arrhythmias account for 25% to 36% of witnessed sudden cardiac arrests (SCA) at home and 38% to 79% of witnessed SCA in public. The goals of ventricular arrhythmia management include symptom relief, improving quality of life, reducing implantable cardioverter defibrillator shocks, preventing deterioration of left ventricular function, reducing risk of arrhythmic death, and potentially improving overall survival. Based on the ACLS guideline, each tachyarrythmia with a pulse should be given synchronized cardioversion, however, when such action could not be performed for various reasons, and showed wide QRS 0,12, intravenous or antiarrthytmia might serve as a possible treatment. If intravena antiarrhytmics are given, amiodarone may be considered. Amiodarone is also effective in preventing recurrence of monomorphic VT. Lidocaine is less effective in terminating VT than procainamide, sotalol and amiodarone. Lidocaine may be considered second-line antiarrthythmic therapy for monomorphic VT.

Characterization and Management of Ventricular Arrhythmia in Myocarditis

Characterization and Management of Ventricular Arrhythmia in Myocarditis

Management of ventricular arrhythmias in heart failure: Current perspectives.

Congestive heart failure (HF) is a progressive affliction defined as the inability of the heart to sufficiently maintain blood flow. Ventricular arrhythmias (VAs) are common in patients with HF, and conversely, advanced HF promotes the risk of VAs. Management of VA in HF requires a systematic, multimodality approach that comprises optimization of medical therapy and use of implantable cardioverter-defibrillator and/or device combined with cardiac resynchronization therapy. Catheter ablation is one of the most important strategies with the potential to abolish or decrease the number of recurrences of VA in this population. It can be a curative strategy in arrhythmia-induced cardiomyopathy and may even save lives in cases of an electrical storm. Additionally, modulation of the autonomic nervous system and stereotactic radiotherapy have been introduced as novel methods to control refractory VAs. In patients with end-stage HF and refractory VAs, an institution of the mechanical circulatory support device and cardiac transplant may be considered. This review aims to provide an overview of current evidence regarding management strategies of VAs in HF with an emphasis on interventional treatment.

Ventricular arrhythmia management in patients with genetic cardiomyopathies.

Genetic cardiomyopathies are associated with increased risk for cardiac arrhythmias and sudden cardiac death. The management of ventricular arrhythmias (VAs) in patients with these conditions can be nuanced due to particular disease-based considerations, yet data specifically addressing management in these patients are limited. Here we describe the current evidence-based approach to the management of ventricular rhythm disorders in patients with genetic forms of cardiomyopathy, namely, hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, left ventricular noncompaction, and Brugada syndrome, including recommendations from consensus guideline statements when available.

Prevalence, Outcomes, and Management of Ventricular Arrhythmias in COVID-19 Patients.

We review the current data on epidemiology, the clinical significance, the pathophysiologic mechanisms, and the treatment of VAs in the setting of COVID-19. VAs prevail in 0.15% to 8% of hospitalized patients, but only sustained and rapid tachyarrhythmias are purportedly associated with a significant increase in mortality. Multiple factors can elicit VAs, which are ultimately deemed to be a marker of severe systemic disease rather than a distinct cardiac condition. Even though the electrophysiologist plays a determinant role in the secondary prevention of VAs, a multidisciplinary approach is indispensable for primary prophylaxis and acute management.

Procainamide pharmacokinetics during extracorporeal membrane oxygenation.

Procainamide is a useful agent for management of ventricular arrhythmia, however its disposition and appropriate dosing during extracorporeal membrane oxygenation (ECMO) is unknown. We report experience with continuous procainamide infusion in a critically ill adult requiring venoarterial ECMO for incessant ventricular tachycardia. Pharmacokinetic analysis of procainamide and its metabolite, N-acetylprocainamide (NAPA), was performed using serum and urine specimens. Kidney function was preserved, and sequencing of the N-acetyltransferase 2 gene revealed the patient was a phenotypic slow acetylator. Procainamide volume of distribution and half-life were calculated and found to be similar to healthy individuals. However, despite elevated serum procainamide concentrations, NAPA concentrations remained far lower in the serum and urine. The magnitude of procainamide and NAPA discordance suggested alternative contributors to the deranged pharmacokinetic profile, and we hypothesized NAPA sequestration by the ECMO circuit. Ultimately, the patient received orthotopic cardiac transplantation and was discharged home in stable condition. Procainamide should be used cautiously during ECMO, with close therapeutic drug monitoring of serum procainamide and NAPA concentrations. The achievement of therapeutic NAPA concentrations while maintaining safe serum procainamide concentrations during ECMO support may be challenging.

Management of ventricular tachycardia in patients with cardiac sarcoidosis.

Sarcoidosis is a multisystem granulomatous disease with 2 different phases (inflammation and scar). In the current era of targeted use of implantable cardioverter-defibrillators and modern heart failure therapy, recent data indicate the prognosis of cardiac sarcoidosis (CS) is much improved, and hence more patients are presenting with recurrent ventricular tachycardia (VT). This review highlights our current understanding of the pathophysiology and management of ventricular arrhythmias in CS with the major focus on indications, techniques, and outcomes of ablation.It is likely macroreentry phenomena around areas of fibrosis is the most frequent mechanism of ventricular arrhythmia in CS. It is also possible that inflammation may play a role in initiating reentry with ventricular ectopy in CS patients, or by slowing conduction in diseased tissue. The best available data would suggest annual rates of VT of perhaps 1%–2% and 10%–15% in patients with initially clinically silent and clinically manifest disease, respectively. Current guidelines recommend a stepwise approach to VT management. The first suggested step is treatment with immunosuppression if there is evidence of active inflammation. Antiarrhythmic medications are often started at the same time, with catheter ablation considered if VT cannot be controlled. Activation and entrainment mapping and ablation are favored in the setting of hemodynamically tolerated VT. Substrate ablation targets areas of abnormal electrogram and favorable pace mapping using linear and/or cluster lesion sets with the goal of abolishing critical isthmuses and/or blocking VT exit sites. Epicardial mapping ablation is required in 20%–35% of cases. In general, more morphologies of VT are induced (often 3–4) and subsequent outcomes (recurrence rates 40%–50%) are less favorable than in other forms of nonischemic cardiomyopathy.The prognosis of CS is much improved and, as a result, more patients are developing VT during follow-up. Likely principally related to the complex disease substrate, VT ablation is technically challenging, with moderate outcomes, and much remains to be learned.

Ablation therapy for ventricular arrhythmias in patients with LVAD: Multiple faces of an electrophysiological challenge.

Left ventricular assist device implantation is a recognized treatment option for patients with advanced heart failure refractory to medical therapy and can be used both as bridge to transplantation and as destination therapy. The risk of ventricular arrhythmias is common after left ventricular assist device implantation and is influenced by pre‐, peri and post‐operative determinants. The management of ventricular arrhythmias can be a challenge when they become refractory to medication or to device therapy and their impact on prognosis can be detrimental despite the mechanical support. In this setting, catheter ablation is being increasingly recognized as a feasible option for patients in which standard therapeutic strategies fail, but also with preventive purpose. Catheter ablation is being increasingly considered for the management of ventricular arrhythmias in patients with left ventricular assist device despite complex clinical and technical peculiarities due to the characteristics of the mechanical support. Much conflicting data exist regarding the predictors of success of the procedure and the rate of recurrence. In this review we discuss the latest evidences regarding catheter ablation of ventricular arrhythmias in this subset of patients, focusing on clinical characteristics, arrhythmia etiology, technical aspects and postprocedural features which must be considered by the electrophysiologist.