Recurrent Ventricular Arrhythmias Research Articles

Ventricular Arrhythmias in Patients with Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome in young women, with a wide clinical spectrum of severity. Ventricular arrhythmia (VA) can occur and worsen prognosis. The current study compared in-hospital and follow-up adverse cardiovascular events in patients with and without VA at presentation. Eighty-three cases of SCAD were collected retrospectively from 4 Gulf countries (KSA, UAE, Kuwait, and Bahrain) during the period from January 2011 to December 2017. We divided the patients into 2 groups: those with and without VA at presentation. VA was defined as ventricular tachycardia and/or ventricular fibrillation. In-hospital (recurrent VA, cardiogenic shock, death, implantable cardioverter-defibrillator placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) events were compared among the 2 groups. The median age of patients in the study was 44 (37-55) years. Forty-two (51%) were women. VA occurred in 10 (12%) patients in the first 24-hour of hospitalization, and 5 (50%) of those patients had recurrent in-hospital VA. Among those with recurrent VA, 1 died during hospitalization and 1 died within the first year following hospital discharge. In-hospital adverse cardiovascular events were significantly more frequent for patients with SCAD who presented with VA. However, follow-up events were not statistically significant between those with and without VA at presentation.

Outcomes of catheter ablation of ventricular arrhythmia originating from the left ventricular summit: A multicenter study

Catheter ablation has been considered an effective strategy for the treatment of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS). However, the inherent complexity of the anatomy of the LVS may result in failed ablation or recurrence of VA. The purpose of this multicenter study was investigate the procedural outcomes of ablation of LVS VA. A total of 238 patients (54.6% men; mean age 53.2 ±15.0 years) undergoing catheter ablation of LVS VA were included. Baseline characteristics, procedural parameters, and clinical outcomes were analyzed. Acute procedural success was achieved in 199 patients (83.6%). Initial epicardial ablation via the coronary venous system (93.8% [91/97]) or percutaneous transpericardial approach (6.2% [6/97]) achieved successful ablation in 40 of 97 patients (41.2%), and VA was eliminated by initial approaches from the aortic sinus of Valsalva or subvalvular endocardium in 68 of 139 patients (48.9%; P = .29). Multisite ablations were performed in the process of acute VA elimination in 105 patients (51.8%), and 7 complications occurred. During median follow-up of 26 (1-87) months, 82.2% of patients with acute success were free from VA recurrences, and the overall long-term success rate was 68.1%. Multisite ablation was the only independent predictor of VA recurrences. Acute elimination of VA originating from the LVS could be achieved in 83.6% of patients, with 82.2% having no VA recurrences. Despite acute elimination of VA with multisite ablation, the incidence of VA recurrence still was high.

Severe Prinzmetal’s Angina Inducing Ventricular Fibrillation Cardiac Arrest

Prinzmetal's angina is a vascular spasm of the coronary artery that can mimic acute coronary syndrome. It is rarely responsible for ventricular arrhythmias and cardiac arrest; however, survivors with these complications are at increased risk for recurrent ventricular arrhythmias and sudden cardiac death. This is true despite the presence of normal cardiac function and optimal medical therapy. Thus, this select population should be considered for an implantable cardioverter defibrillator (ICD). In this case vignette, we describe a healthy 48-year-old female with ventricular fibrillation arrest, followed by recurrent ventricular tachyarrhythmias caused by Prinzmetal's angina.

Acute management of ventricular tachycardia.

Acute management of patients with ventricular arrhythmia (VA) is aimed at immediate VA termination if the patient is hemodynamically instable and early termination after initial diagnostic work-up if tolerated. Prolonged episodes of VA may lead to hemodynamic and metabolic decompensation and early resumption of normal ventricular activation is warranted. Termination is best performed by electrical cardioversion, anti-tachycardia pacing (if available, in cases with an implanted defibrillator [ICD]) or defibrillation. Antiarrhythmic drug treatment may lead to rhythm stabilization in cases of VA recurrence. Scrutinizing the electrocardiogram (ECG) of VA is extremely helpful to differentiate potential mechanisms, underlying cardiac pathologies and identify treatment options, as well as a differential diagnosis if a ventricular origin is unclear. In general, structural VA should be differentiated from idiopathic and non-structural (idiopathic) VA. On the other hand, based on ECG morphology VA should be classified into monomorphic versus polymorphic ventricular tacyhcardia (VT)/ventricular fibrillation (VF). Polymorphic VT/VF may be related to reversible causes as well as genetically determined arrhythmia syndromes and aspecialized treatment pathway may be chosen: (1)VA termination, (2)evaluation and treatment of potential VA causes, (3)acute (medical treatment) and chronic (interventional treatment using catheter ablation) prevention of recurrence and (4)treatment of underlying heart disease, if identified, are crucial pillars of VA management. These patients can be managed in dedicated VT units and by multispecialty teams integrating all potential aspects of rhythm stabilization and treating underlying cardiac abnormalities. Heart failure management in patients with reduced left ventricular function may be crucial for the long-term prognosis.

Clinical evaluation and current trends in the diagnosis and treatment of Brugada syndrome

Brugada syndrome (BrS) is a cardiac channelopathy associated with an increased risk of unexplained syncope, life-threatening ventricular arrhythmia, or sudden cardiac death. The patients with BrS often have the arrhythmia at rest or while asleep. It could also be triggered by fever or medications. About 15% of those with BrS have a family history of this condition. BrS is diagnosed by identifying ST segment elevation in leads V1–V2 with a right bundle branch block-like appearance of standard 12-lead electrocardiogram (ECG) placed in the fourth intercostal space. The ST segment elevation could also be unmasked or become more obvious by placing lead V1–V2 in the second and third intercostal spaces. In some patients, the ECG shows a prolonged PR interval but normal QTc interval. The first-line therapy for patients with BrS presenting with prior cardiac arrest or documented ventricular tachycardia is an implantable cardioverter-defibrillator (ICD). In the cases with recurrent ventricular arrhythmia or electrical storm, pharmacological therapy with quinidine is recommended as an adjunct to an ICD. This article is an overview of the clinical evaluation and current trends in the diagnosis and treatment of BrS.

High risk of sustained ventricular arrhythmia recurrence after acute myocarditis

Acute myocarditis is associated with cardiac arrhythmia in 25% of cases; a third of these arrhythmias are ventricular tachycardia (VT) or ventricular fibrillation (VF). The implantation of a cardiac defibrillator (ICD) following sustained ventricular arrhythmia remains controversial in these patients. We sought to assess the risk of major arrhythmic ventricular events (MAE) over time in patients implanted with an ICD following sustained VT/VF in the acute phase of myocarditis compared to those implanted for VT/VF occurring on myocarditis sequelae. Our retrospective observational study included patients implanted with an ICD following VT/VF during acute myocarditis or VT/VF on myocarditis sequelae, from 2007 to 2017, in 15 French university hospitals. MAE was defined as any appropriate intervention of the defibrillator (antitachycardia pacing or shock) on VT/VF. Over a median follow-up period of 3 years, 11(39%) patients of the acute myocarditis group and 24(60%) patients of the myocarditis sequelae group experienced one or more MAE. Kaplan–Meier MAE rate estimates at one and three years follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group, respectively. There was no significant difference in the number or type of MAEs in the two groups. Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results challenge current guidelines for ICD implantation in acute myocarditis associated with VT/VF by showing that the risk of MAE recurrence remains high after the resolution of the acute episode.

Incidence, Predictors, and Success of Ventricular Tachycardia Catheter Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy (from the Nordic ARVC Registry)

Catheter ablation may reduce ventricular tachycardia (VT) burden in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. However, little is known about factors predicting need for ablation. Therefore, we sought to investigate predictors and use of VT ablation and to evaluate the postprocedural outcome in ARVC patients. We studied 435 patients from the Nordic ARVC registry including 220 probands with definite ARVC according to the 2010 task force criteria and 215 mutation-carrying relatives identified through cascade screening. Patients were followed until first-time VT ablation, death, heart transplantation, or January 1st 2018. Additionally, patients undergoing VT ablation were further followed from the time of ablation for recurrent ventricular arrhythmias. The cumulative use of VT ablation was 4% (95% confidence interval [CI] 3% to 6%) and 11% (95% CI 8% to 15%) after 1 and 10 years. All procedures were performed in probands in whom cumulative use was 8% (95% CI 5% to 12%) and 20% (95% CI 15% to 26%). In adjusted analyses among probands, only young age predicted ablation. In patients undergoing ablation, risk of recurrent arrhythmias was 59% (95% CI 44% to 71%) and 74% (95% CI 59% to 84%) 1 and 5 years after the procedure. Despite high recurrence rates, the burden of ventricular arrhythmias was reduced after ablation (p = 0.0042). Young age, use of several antiarrhythmic drugs and inducibility to VT after ablation were associated with an unfavorable outcome. In conclusion, twenty percent of ARVC probands developed a clinical indication for VT ablation within 10 years whereas mutation-carrying relatives were without such need. Although the burden of ventricular arrhythmias decreased after ablation, risk of recurrence was substantial.

Terapia ablativa en un caso de síndrome de Brugada con tormenta eléctrica

Patients with Brugada syndrome may have malignant ventricular arrhythmias and sudden cardiac death. Thus, these patients frequently have indication of implantable cardioverter defibrillator. Occasionally, these patients may experience recurrent appropriate cardioverter defibrillator shocks refractory to medical treatment. Recent reports indicate that radiofrequency ablation in Brugada syndrome is feasible, and effective.A 55-year-old woman with Brugada syndrome and an electrical storm, underwent three-dimensional electroanatomic mapping and radiofrequency ablation. During electrophysiological study there were no spontaneous or inducible arrhythmias. Voltage mapping of the right ventricle was created in sinus rhythm and both, endocardial and epicardial substrate modification of right ventricular outflow tract was performed. Brugada ECG pattern resolved post procedure.Follow up at 4 months revealed no recurrence of ventricular arrhythmias or Brugada electrocardiographic pattern.Radiofrequency mediated therapy for substrate modification in patients with Brugada syndrome and an electricalstorm, may be useful in their critical care management.

Ablation Therapy for Refractory Ventricular Arrhythmias.

Recurrent ventricular arrhythmias (VAs) are a leading cause of cardiovascular morbidity and mortality. In the last three decades, important advancements have occurred in the understanding of the mechanisms of recurrent VAs, their prognostic implications in different clinical contexts, and their treatment options. VAs occur in structurally normal hearts as well as in patients with underlying heart disease, but the latter group has a particularly high risk of recurrent VAs. Catheter ablation offers the possibility of cure for a substantial proportion of patients. Research has focused on identifying optimal targets for ablation, correlating the underlying structural abnormalities with the site of origin of VAs, and determining the optimal procedural approach. Ablation therapy can be life-saving in select patients with high burden of repetitive VAs or advanced heart failure syndromes. This article focuses on clinical aspects of catheter ablation of VAs, particularly the selection and clinical management of patients undergoing catheter ablation procedures and expected outcomes.

Atrial Fibrillation Is Associated with Recurrent Ventricular Arrhythmias After LVAD Implant: Incidence and Impact in a Consecutive Series.

This study examined left-ventricular assist device (LVAD) patients with pre-LVAD ventricular arrhythmias (VAs) to determine the rate of recurrent post-LVAD VAs and the impact of pre-LVAD atrial fibrillation (AF) on recurrent post-LVAD VAs. Medical records of 195 consecutive LVAD patients were reviewed. Descriptive statistics were generated and Cox proportional hazard models were used to assess the association of clinical variables with the time to recurrent VA. Forty-seven percent of 195 CHF patients who received LVAD-manifested significant VAs prior to LVAD implant (82% Heartmate II, 14% HVAD, 4% other; median follow-up = 17months), 41% of whom manifested recurrent post-LVAD VAs. Pre-LVAD AF was associated with recurrent VAs (hazard ratio = 3.73; 95% CI 1.33, 10.48; p = 0.012). Recurrent VAs were associated with increased mortality (hazard ratio = 3.06; 95% CI 1.17, 7.98; p = 0.023). A history of AF is prevalent in over half of LVAD patients with recurrent VAs and is associated with time to recurrence of VA.

Ventricular Arrhythmias in Patients With Left Ventricular Assist Device (LVAD)

Left ventricular assist device (LVAD) implantation is a well-known treatment option for patients with advanced heart failure refractory to medical therapy and is recognized both as bridge to transplant and a destination therapy. The risk of ventricular arrhythmias (VAs) is common after LVAD implantation. We review the pathophysiology and recent advances in the management of VA in LVAD patients. VAs are most likely to occur in the early post-operative periods after LVAD implantation and a prior history of VA is the most important risk factor. Post-LVAD VAs are usually well tolerated with less morbidity and decreased risk of sudden cardiac death. However, risk of right heart failure in the setting of persistent VAs is being increasingly recognized. The mechanisms of post-LVAD VAs may vary depending on the time from LVAD implantation. Electrical remodeling may play an important role in the immediate post-implant phase. Preexisting myocardial scar and to a lesser extent mechanical irritation from the LVAD cannula are important in the later phases. Most LVAD patients have a previously placed implantable cardioverter-defibrillator (ICD). The benefit of implanting a new ICD in LVAD patients is unknown and should be individualized. For ICD programming, a conservative strategy with higher detection zones and prolonged time to detection is usually recommended aiming to minimize ICD shocks. More aggressive programming is appropriate if the VA results in hemodynamic instability. Antiarrhythmic drugs including amiodarone, mexiletine, and beta blockers are usually the first-line therapy for VAs. Catheter ablation has been shown to be safe and effective in LVAD recipients with recurrent VAs not responsive to antiarrhythmic drugs. LVAD-related VA is most frequently reentrant secondary to myocardial scar and usually well tolerated. Management options include antiarrhythmic drugs and catheter ablation.

Acute compartment syndrome of the lower leg causing cardiac arrest after resection of the right external iliac vein for autologous graft: a case report

BackgroundThe right external iliac vein (REIV) is often used for portal vein reconstruction in patients undergoing pancreatoduodenectomy with portal-superior mesenteric vein resection. We report a case of cardiac arrest caused by acute lower leg compartment syndrome as a result of REIV resection.Case presentationA 53-year-old man underwent pancreatoduodenectomy with portal vein resection. Hyperkalemia progressed during surgery due to intestinal reperfusion injury, which caused recurrent ventricular arrhythmia required for cardio-pulmonary resuscitation. The surgery was discontinued after resuscitation, and portal vein reconstruction using the REIV was performed 2 days post-operatively. Acute compartment syndrome was diagnosed immediately following the surgery. Hyperkalemia progressed, causing pulseless ventricular tachycardia. Emergent fasciotomy was performed, but right leg dysfunction persisted after discharge.ConclusionREIV resection can cause lower-extremity acute compartment syndrome. The status, including intracompartmental pressure, of the lower extremity should be carefully observed after REIV resection during and after surgery.

Risk of subsequent ventricular arrhythmia is higher in primary prevention patients with implantable cardioverter defibrillator than in secondary prevention patients

BackgroundBecause of previous ventricular arrhythmia (VA) episodes, patients with implantable cardioverter-defibrillator (ICD) for secondary prevention (SP) are generally considered to have a higher burden of VAs than primary prevention (PP) patients. However, when PP patients experienced VA, the difference in the prognosis of these two patient groups was unknown.MethodsThe clinical characteristics and follow-up data of 835 ICD patients (364 SP patients and 471 PP patients) with home monitoring feature were retrospectively analysed. The incidence rate and risk of subsequent VA and all-cause mortality were compared between PP patients after the first appropriate ICD therapy and SP patients.ResultsDuring a mean follow-up of 44.72 ± 20.87 months, 210 (44.59%) PP patients underwent appropriate ICD therapy. In the Kaplan-Meier survival analysis, the PP patients after appropriate ICD therapy were more prone to VA recurrence and all-cause mortality than SP patients (P<0.001 for both endpoints). The rate of appropriate ICD therapy and all-cause mortality in PP patients after the first appropriate ICD therapy was significantly higher than that in SP patients (for device therapy, 59.46 vs 20.64 patients per 100 patient-years; incidence rate ratio [IRR] 2.880, 95% confidence interval [CI]: 2.305–3.599; P<0.001; for all-cause mortality, 14.08 vs 5.40 deaths per 100 patient-years; IRR 2.607, 95% CI: 1.884–3.606; P<0.001). After propensity score matching for baseline characteristics, the risk of VA recurrence in PP patients with appropriate ICD therapy was still higher than that in SP patients (41.80 vs 19.10 patients per 100 patient-years; IRR 2.491, 95% CI: 1.889–3.287; P<0.001), but all-cause mortality rates were similar between the two groups (12.61 vs 9.33 deaths per 100 patient-years; IRR 1.352, 95% CI: 0.927–1.972; P = 0.117).ConclusionsOnce PP patients undergo appropriate ICD therapy, they will be more prone to VA recurrence and death than SP patients.

P2875Comparison between ejection fraction, global longitudinal strain, mechanical dispersion and delta contraction duration in predicting first and subsequent arrhythmic events in ICD patients

Abstract Background According to current guidelines, left ventricular ejection fraction (LVEF) is currently the most important parameter for primary prevention of sudden cardiac death in patients with structural heart disease. Unfortunately, LVEF has low sensitivity in detecting arrhythmic events and presents a significant intra- and inter-operator variability. For these reasons, alternative predictors in patients with structural heart disease are being sought. Among those, speckle-tracking derived parameters such as global longitudinal strain (GLS), mechanical dispersion (MD), and delta contraction duration (DCD) have been proposed as better alternatives. Purpose To assess speckle-tracking derived parameters as predictors of first and subsequent arrhythmic events in implantable cardioverter-defibrillator (ICD) patients with structural heart disease, and to compare their performance with LVEF. Methods Prospective, observational study enrolling all consecutive patients with structural heart disease admitted for an ICD implant. Patients not followed by a home-monitoring system were excluded. 2D speckle-tracking analysis was used to derive GLS, MD, and DCD of all patients at enrolment. Home monitoring was checked weekly in order to detect all ventricular arrhythmias (VA) and ICD therapies. A recurrent-event statistical approach (Prentice, Williams, and Peterson model) was applied in order to evaluate subsequent events after the first ones. Results Two-hundred-and-three patients were consecutively enrolled and followed-up for a median follow-up of 2.2 years. Kaplan-Meier curves showed an increased risk of ATP or shock (Log-rank p=0.003) and VAs (Log-rank p=0.001) associated with lower quartiles of GLS (Figure 1). An impaired GLS was independently associated with an increased risk for the first ICD therapy (HR 1.94; 95% CI 1.30–2.91; p=0.001), and for the first VA (HR 1.42; 95% CI 1.01–1.98; p=0.04). GLS impairment was not significantly associated with an increased risk of recurrent ICD therapies or VAs. LVEF, MD and DCD were not associated with an increased risk of first, second and third ICD therapy or VA. Conclusions Impaired GLS is associated with an increased risk of VAs and appropriate ICD therapies in a consecutive, “real-world”, unselected population of remote-monitored patients with structural heart disease, although it does not seem reliable in predicting further arrhythmic event after the first one. LVEF, MD, and DCD do not predict first or subsequent arrhythmic events in ICD patients with structural heart disease. Acknowledgement/Funding Marche Polytechnic University

P5698What predicts the inefficiency of stellate ganglion block in the treatment of electrical storm?

Abstract Introduction Electrical storm (ES) is an emergent condition which requires a sofisticated approach. Massive sympathetic surge almost always connected with ES precipitates recurrent ventricular arrhythmias. Performing stellate ganglion block (SGB) to alleviate the sympathetic activity on myocardium is becoming a standard of care in many centers. However, there is no clear data to predict in which patients the SGB will be ineffective. Purpose To identify predictors of SGB failure in patients with ES. Methods We analyzed our case series of SGB – the procedure was performed in 31 patients with ES in our center from March 2017 to December 2018. Results Mean left ventricular ejection fraction was 27% (±9%), 74% of patients had ischaemic cardiomyopathy. The most frequent type of arrhythmia was monomorphic ventricular tachycardia (VT), occurring in 71% of patients, followed by polymorphic VT in 13% of cases. After SGB, the burden of ventricular arrhythmias failed to decrease by at least 50% in 10% of cases - these patients were marked as non-responders. Slow monomorphic VT (under 160/min) was observed in all of these patients. On the other hand, fast monomorphic VT or polymorphic VT seemed to respond very well to SGB. We also observed, that patients with ES after acute coronary syndromes were good responders as well. The effect of SGB was not related to age, gender, EF LK or the etiology of cardiomyopathy. Conclusions According to our experience, the failure of SGB in the treatment of ES is not frequent. It typically occurs in patients with slow monomorphic VT. It is probable that such arrhythmias are sustained primarily due to the extensive myocardial substrate, and not because of the sympathetic surge. The situation is quite the opposite in patients with fast VT and acute ischemia.

P992Incidence, predictors, and success of ventricular tachycardia catheter ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC): A long-term cohort study from the Nordic ARVC registry

Abstract Background Catheter ablation may reduce ventricular tachycardia (VT) burden in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. However, little is known about factors predicting need for ablation and various outcomes have been reported. Purpose We sought to investigate predictors and use of VT ablation and to evaluate the post-procedural outcome in ARVC patients. Methods We studied 435 patients from the Nordic ARVC registry including 220 probands with definite ARVC according to the 2010 task force criteria and 215 mutation-carrying relatives identified through cascade screening. Patients were followed until first-time VT ablation, death, heart transplantation, or January 1st 2018. Additionally, patients undergoing VT ablation were further followed from the time of ablation for recurrent ventricular arrhythmias. Results Cumulative use of VT ablation was 4% (95% CI 3%-6%) and 11% (95% CI 8%-15%) after 1 and 10 years. All procedures were performed in probands in whom the cumulative use was 8% (95% CI 5%-12%) and 20% (95% CI 15%-26%). In adjusted analyses restricted to probands, only young age predicted need for ablation. In patients undergoing ablation, risk of recurrent arrhythmias was 59% (95% CI 44%-71%) and 74% (95% CI 59%-84%) 1 and 5 years after the procedure. Despite high recurrence rates, the burden of ventricular arrhythmias was reduced after ablation (p=0.0042). Young age, use of several antiarrhythmic drugs and inducibility to VT immediately after ablation were associated with an unfavorable outcome. Conclusions Twenty percent of ARVC probands developed a clinical indication for VT ablation within 10 years after diagnosis whereas mutation-carrying relatives were without such need. Although the burden of ventricular arrhythmias decreased after ablation, risk of recurrence was substantial.

Catheter ablation of ventricular arrhythmias originating from the para-Hisian region with reversed C-curve technique.

Ventricular arrhythmias (VAs) originating from the para-Hisian region represent a challenging location. The long-term success rate of catheter ablation above the septal leaflet of the tricuspid valve is not ideal. This study aimed to investigate the safety and efficacy of catheter ablation for para-Hisian VAs via a direct approach under the septal valve with reversed C-curve technique. Twenty-five consecutive patients with para-Hisian VAs were included. Systematic mapping was performed in the right ventricle septum, including both the regions above and under the septal valve. Radiofrequency (RF) ablation was preferentially performed under the valve with reversed C-curve technique in all patients. If the ablation failed under the valve, it was then performed above the valve and even in aortic sinus cusps. The earliest ventricular activation preceding surface QRS (V-QRS) under the valve was significantly larger than that above the valve (34.8 ± 5.3 vs 27.8 ± 5.7 ms, P < .01). RF ablation under the valve with reversed C-curve technique achieved acute success in 22 of 25 (88%) patients. Junctional rhythm developed during ablation in 3 of 25 (12%) patients and no atrioventricular block occurred. In the remaining three patients, RF application above the valve failed to eliminate the VAs and one of them achieved successful ablation in the right coronary cusp. During a mean follow-up of 17.8 ± 9.4 months, no patients presented with VAs recurrence and no postprocedure complications occurred. Catheter ablation under the valve with reversed C-curve technique shows to be effective and safe for para-Hisian VAs.

Isoproterenol and Lidocaine for Recurrent Torsades de Pointes in a 32-year-old Pregnant Woman

Guidelines recommend magnesium and defibrillation for Torsades de Pointes (TdP) treatment in pregnancy, both of which were unsuccessful at terminating our patient's recurrent ventricular arrhythmias. Both lidocaine and isoproterenol carry potential risks to mother and fetus, but the risk of congenital abnormalities is significantly lower compared to other antiarrhythmics such as amiodarone.

Catheter ablation in highly symptomatic Brugada patients: a Dutch case series.

In the past few years, promising results were described in targeting the arrhythmogenic substrate of the epicardial right ventricular outflow tract (RVOT) region in patients with Brugada syndrome (BrS). In this report, we describe our experience with endo- and epicardial substrate mapping and ablation in a series of highly symptomatic BrS patients. This case series consists of seven patients with clinical BrS diagnosis who underwent catheter ablation in two Dutch hospitals (Isala hospital Zwolle; and Amsterdam University Medical Centre, location AMC, Amsterdam) and Hamad Heart Hospital in Qatar between 2013 and 2017. All patients had an ICD and recurrent ventricular arrhythmia (VA) episodes. All patients underwent endo-and epicardial mapping of the RVOT region. Elimination of all abnormal potentials and disappearance of BrS ECG pattern during the ablation procedure was the aimed endpoint. The study group consisted of seven patients with mean age 45.6 ± 16.9years. Five patients had SCN5A mutations. One patient was excluded from analysis, since ablation could not be performed due to a very large low-voltage area and was later diagnosed with arrhythmogenic right ventricular cardiomyopathy, associated with an SCN5A mutation. One patient underwent both endo- and epicardial ablation to eliminate VA. During a mean follow-up of 3.6 ± 1.5years, 5/6 patients remained VA free with two patients continuing quinidine. In patients with BrS and drug-refractory VA, ablation of the arrhythmogenic substrate in the RVOT region was associated with excellent long-term VA-free survival. The majority of these highly symptomatic BrS patients had an SCN5A mutation and also low-voltage areas epicardially.

Effective Use of Percutaneous Stellate Ganglion Blockade in Patients With Electrical Storm.

Percutaneous stellate ganglion blockade (SGB) has been used for drug-refractory electrical storm due to ventricular arrhythmia (VA); however, the effects and long-term outcomes have not been well studied. This study included 30 consecutive patients who had drug-refractory electrical storm and underwent percutaneous SGB between October 1, 2013, and March 31, 2018. Bupivacaine, alone or combined with lidocaine, was injected into the neck with good local anesthetic spread in the vicinity of the left stellate ganglion (n=15) or both stellate ganglia (n=15). Data were collected for patient clinical characteristics, immediate and long-term outcomes, and procedure-related complications. Clinical characteristics included age, 58±14 years; men, 73.3%; and left ventricular ejection fraction, 34±16%. At 24 hours, 60% of patients were free of VA. Patients whose VA was controlled had a lower hospital mortality rate than patients whose VA continued (5.6% versus 50.0%; P=0.009). Implantable cardioverter-defibrillator interrogation showed a significant 92% reduction in VA episodes from 26±41 to 2±4 in the 72 hours after SGB (P<0.001). Patients who died during the same hospitalization (n=7) were more likely to have ischemic cardiomyopathy (100% versus 43.5%; P=0.03) and recurrent VA within 24 hours (85.7% versus 26.1%; P=0.009). There were no procedure-related major complications. SGB effectively attenuated electrical storm in more than half of patients without procedure-related complications. Percutaneous SGB may be considered for stabilizing ventricular rhythm in patients for whom other therapies have failed.