Advertisement

Empiric ablation of polymorphic ventricular tachycardia/fibrillation in the absence of a mappable trigger: Prospective feasibility and efficacy of pacemap matching to defibrillator electrograms

Published:October 29, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.10.025

      Background

      Catheter ablation strategies for ventricular fibrillation (VF) and polymorphic ventricular tachycardia (PMVT) are not established when spontaneous triggers are rare or absent.

      Objective

      The purpose of this study was to report the feasibility and efficacy of a novel empiric ablation strategy of pacemapping to stored implantable cardioverter-defibrillator (ICD) template electrograms (SITE) of the clinical premature ventricular contraction (PVC) trigger.

      Methods

      Fifteen patients with drug-refractory VF/PMVT receiving defibrillator shocks without identifiable and mappable PVC triggers were prospectively analyzed. The protocol incorporated systematic pacemapping from known arrhythmogenic sites (moderator band/right ventricular [RV] papillary muscles, left conduction system/Purkinje network, outflow tracts) with real-time comparison between the paced ICD electrogram (EGM) morphology and SITE.

      Results

      Regions within the left Purkinje network yielded the best pacemap match for the SITE of the clinical PVC trigger in 55% of ablation targets (left posterior fascicle 6, left septal fascicle 1, left anterior fascicle 5), followed by the RV moderator band region in 14% (n = 3), RV papillary muscles in 13% (n = 3), periaortic region in 14% (n = 3), and left ventricular anterolateral papillary muscle in 4% (n = 1). Freedom from ICD therapies off antiarrhythmic drug (AAD) was 64% at 6 months and 48% at 12 months. Shock burden was reduced from 4 (2–6) to 0 (0–1) (P = .001), and use of AADs was reduced from 2 (1–2) to 0 (0–1) (P = .001).

      Conclusion

      In the absence of a mappable trigger, an empiric strategy of interrogating the Purkinje network, papillary muscles, and outflow tract regions by pacemap matching with SITE of the clinical PVC is feasible to guide ablation. A significant reduction in VF/PMVT therapy burden and AAD utilization was observed after a single procedure.

      Graphical abstract

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Haïssaguerre M.
        • Shah D.C.
        • Jaïs P.
        • et al.
        Role of Purkinje conducting system in triggering of idiopathic ventricular fibrillation.
        Lancet. 2002; 359: 677-678
        • Knecht S.
        • Sacher F.
        • Wright M.
        • et al.
        Long-term follow-up of idiopathic ventricular fibrillation ablation. A multicenter study.
        J Am Coll Cardiol. 2009; 54: 522-528
        • Zipes D.P.
        • Camm A.J.
        • Borggrefe M.
        • et al.
        American College of Cardiology/American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association; Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
        Circulation. 2006; 114: e385-e484
        • Van Herendael H.
        • Zado E.S.
        • Haqqani H.
        • et al.
        Catheter ablation of ventricular fibrillation: Importance of left ventricular outflow tract and papillary muscle triggers.
        Heart Rhythm. 2014; 11: 566-573
        • Santoro F.
        • Biase L. Di
        • Hranitzky P.
        • et al.
        Ventricular fibrillation triggered by PVCs from papillary muscles: clinical features and ablation.
        J Cardiovasc Electrophysiol. 2014; 25: 1158-1164
        • Nogami A.
        Mapping and ablating ventricular premature contractions that trigger ventricular fibrillation: trigger elimination and substrate modification.
        J Cardiovasc Electrophysiol. 2015; 26: 110-115
        • Yoshida K.
        • Liu T.Y.
        • Scott C.
        • et al.
        The value of defibrillator electrograms for recognition of clinical ventricular tachycardias and for pace mapping of post-infarction ventricular tachycardia.
        J Am Coll Cardiol. 2010; 56: 969-979
        • Haïssaguerre M.
        • Extramiana F.
        • Hocini M.
        • et al.
        Mapping and ablation of ventricular fibrillation associated with long-QT and Brugada syndromes.
        Circulation. 2003; 108: 925-928
        • Bänsch D.
        • Oyang F.
        • Antz M.
        • et al.
        Successful catheter ablation of electrical storm after myocardial infarction.
        Circulation. 2003; 108: 3011-3016
        • Marrouche N.F.
        • Verma A.
        • Wazni O.
        • et al.
        Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy.
        J Am Coll Cardiol. 2004; 43: 1715-1720
        • Szumowski L.
        • Sanders P.
        • Walczak F.
        • et al.
        Mapping and ablation of polymorphic ventricular tachycardia after myocardial infarction.
        J Am Coll Cardiol. 2004; 44: 1700-1706
        • Peichl P.
        • Čihák R.
        • Koželuhová M.
        • Wichterle D.
        • Vančura V.
        • Kautzner J.
        Catheter ablation of arrhythmic storm triggered by monomorphic ectopic beats in patients with coronary artery disease.
        J Interv Card Electrophysiol. 2010; 27: 51-59
        • Nakamura T.
        • Schaeffer B.
        • Tanigawa S.
        • et al.
        Catheter ablation of polymorphic ventricular tachycardia/fibrillation in patients with and without structural heart disease.
        Heart Rhythm. 2019; 16: 1021-1027
        • Viskin S.
        • Chorin E.
        • Viskin D.
        • et al.
        Quinidine-responsive polymorphic ventricular tachycardia in patients with coronary heart disease.
        Circulation. 2019; 139: 2304-2314
        • Nogami A.
        • Sugiyasu A.
        • Kubota S.
        • Kato K.
        Mapping and ablation of idiopathic ventricular fibrillation from the Purkinje system.
        Heart Rhythm. 2005; 2: 646-649
        • Berenfeld O.
        • Jalife J.
        Purkinje-muscle reentry as a mechanism of polymorphic ventricular arrhythmias in a 3-dimensional model of the ventricles.
        Circ Res. 1998; 82: 1063-1077
        • Komatsu Y.
        • Hocini M.
        • Nogami A.
        • et al.
        Catheter ablation of refractory ventricular fibrillation storm after myocardial infarction: a multicenter study.
        Circulation. 2019; 139: 2315-2325