1. Long Term Outcomes After Catheter Ablation of Recurrent VT in Patients With Cardiac Sarcoidosis
Simon A. Castro, MD; Daniele Muser, MD; Erica Zado, PA; Rajeev K. Pathak, MD, PhD; Jackson J. Liang, DO; Fermin C. Garcia, MD; Mathew D. Hutchinson, MD; Gregory Supple, MD;
David S. Frankel, MD; Michael P. Riley, MD, PhD; David Lin, MD; Robert Schaller, DO; Sanjay Dixit, MD; David J. Callans, MD; Pasquale Santangeli, MD; and Francis E. Marchlinski, MD.
Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA
INTRODUCTION
Table 1. Study Population Characteristics
Age, years
55±10
Male, n (%)
22 (71%)
First clinical manifestation of cardiac disease
Complete AV block, n (%)
8 (26%)
PVC/NSVT, n (%)
10 (32%)
Sustained-VT, n (%)
13 (42%)
Clinical history of syncope, n (%)
15 (48%)
NYHA class≥II , n (%)
2D-Echo
LVEF %, mean±SD
42±15
LVEF≤40%, , n (%)
17 (55%)
Moderate to severe right ventricular dysfunction, n (%)
6 (19%)
Moderate to severe diastolic dysfunction, n (%)
11 (35%)
Time from clinical onset of cardiac disease to ICD implantation, years
1 ( )
Time from clinical onset of cardiac disease to first episode of SVT, years
2 ( )
Medical therapy
Beta-blockers, n (%)
31 (100%)
ACE-i/ARBs, n (%)
23 (74%)
Diuretics, n (%)
9 (29%)
Failed anti-arrhythmic drug, n
2 (1-3)
Amiodarone before procedure, n (%)
18 (58%)
Amiodarone after procedure, n (%)
Figure 1. Example of a patient with CS showing intense active inflammation on the septum (A-arrowheads) and anterolateral wall (A-red arrows) as well as patchy scar involving the same areas (B) who underwent endocardial CA ablation on the basal septum (C-D, red dots) where both a bipolar (C) and unipolar (D) abnormalities were recorded by voltage mapping.
Figure 2A. Overall VT free survival
Figure 3. VT burden reduction among patients who experienced VT recurrence
Catheter ablation (CA) of ventricular tachycardia (VT) in patients with cardiac sarcoidosis (CS) could be challenging due to the complex underlying substrate.
Prior small series have shown a high recurrence rate over short- and mid-term follow-up.
We evaluated the outcomes at the long-term follow-up of CA of VT in pts with CS.
METHODS
We enrolled 31 pts (age 55±10 years, 71% males) with recurrent VT related to CS who underwent RFCA at our Institution.
Diagnosis of CS was established according to HRS criteria.
CA was guided by activation/entrainment mapping for tolerated VT and pacemapping/targeting of abnormal substrate for unmappable VT.
Recurrent VT over follow-up was defined as any sustained VT at ICD interrogation and ECG.
Figure 2
Figure 2B. Death/transplant free survival
Table 2. Procedural Characteristics (44 procedures among 31 patients)
Multiple clinical morphologies
15/31 (48%)
Number of VTs induced
3 (1-5)
Cycle length, ms
369±77
Epicardial mapping, n (%)
11/31 patients (35%)
Epicardial ablation, n (%)
8/31 (26%)
Right ventricular ablation, n (%)
18/31 patients (58%)
Interventricular septum ablation, n (%)
16/31 patients (52%)
Ablation in the coronary cusp region, n (%)
7/31 (26%)
Total procedural time, hours
7.7±2.6
Fluoroscopy time, min
59.9±30.6
Radiofrequency time, min
50.2±41.7
Clinical VT inducible at the end of the first procedure, n (%)
7/31 (23%)
Clinical VT inducible at the end of the last procedure, n (%)
3/31 (10%)
≥1 non-clinical VT inducible at the end of the last procedure, n (%)
6/31 (19%)
mean 11±1 months
CONCLUSIONS
RESULTS
Clinical features of the study population are summarized in Table 1.
The mean left ventricular ejection fraction (LVEF) was 42±15% (14 patients with LVEF≤35%), with 6 (19%) patients presenting significant biventricular involvement.
The main characteristics of the ablation procedures are summarized in Table 2.
RFCA was performed endocardial in all patients. Epicardial mapping was performed in 13 (42%) patients and ablation in 8 (26%) cases. An example of a patient who underwent substrate modification on the basal septum is shown in Figure 1.
In 11 (36%) cases more than one procedure (max 3 procedures) was necessary to achieve the long-term results.
In patients with CS and VT, RFCA is effective in achieving long-term VT freedom in 40% of cases with a substantial improvement in VT burden in many of the remaining patients.
In more than one third of patients multiple procedures are needed to achieve long-term VT control.
At the end of the last procedure, noninducibility for any VT at programmed stimulation was achieved in 21 (68%) of patients.
After a median follow-up of 2.5 years (interquartile range: 1.3 to 5.2 years), 1 (3%) patient died and 4 (13%) underwent heart transplant. Figure 2A.
Overall VT-free survival was 40% at 6-years follow-up. Figure 2B.
Among the 16 (52%) patients with VT recurrences, catheter ablation still resulted in a significant reduction of VT burden with 12/16 (75%) having only isolated (≤3 over 11±1 months) VT episodes and a single patient with recurrent VT storm. Figure 3.
DISCLOSURES
None pertinent to this study
SOURCE OF FUNDING
Supported in part by The Richard T. and Angela Clark Innovation Fund in Cardiac Electrophysiology and The F. Harlan Batrus Research Fund