Catheter ablation in patients with ventricular fibrillation by purkinje de-networking

Abstract

BackgroundVentricular fibrillation (VF) is a leading cause of cardiovascular death worldwide. However, recurrence rates of arrhythmia are high leading to mortality and morbidity. Recently, Purkinje fibers have been identified as potential sources of VF initiation and maintenance.AimThe study analyzes the feasibility and effectiveness of catheter ablation in patients with recurrent VF by specific Purkinje de-networking (PDN).MethodsConsecutive patients with recurrent VF undergoing PDN were included in this observational study. The procedural endpoint was the non-inducibility of sustained ventricular arrhythmia. A three-dimensional -anatomical mapping was conducted, and the specific cardiac conduction system and Purkinje fibers were tagged. All detectable Purkinje signals were ablated in the left ventricle (LV). Additional right ventricular (RV) PDN was performed in case of VF inducibility after LV ablation. Follow-up was performed by patient visits at our outpatient clinic including device interrogation and by telephone interviews.ResultsEight patients were included in the study. Six patients were females (75%); the median age during the procedure was 43 [37;57] years and the median body mass index was 24 [23;33] kg/m2. Four patients (50%) had known structural heart disease with two cases of ischemic cardiomyopathy and two cases of dilated cardiomyopathy. In four patients (50%), no underlying structural heart disease could be identified. The median LV ejection fraction was 42 ± 16.4%. All patients had an implantable cardioverter-defibrillator (ICD) prior to ablation with documentation of recurrent VF. The median number of ICD shocks before the ablation was 5 [3;7]. LV PDN was performed in all patients. In two patients (25%), an additional RV PDN was performed. Non-inducibility of any ventricular arrhythmia was achieved in all patients after PDN. Two patients showed complete left bundle branch block post-ablation. The median follow-up duration was 264 [58;421] days. Two patients (25%) experienced ventricular arrhythmia recurrence with recurrent ICD-shock delivery. One patient died during follow-up with an unknown cause of death. Six patients (75%) experienced no arrhythmia recurrence during follow-up.ConclusionPurkinje de-networking represents a novel treatment option for patients with recurrent VF without arrhythmia substrate or specific arrhythmia triggers with promising results in terms of efficiency and feasibility. Larger and more prospective studies are needed for a systematic evaluation.

Purkinje de-networking using a ripple map with a novel multielectrode mapping catheter for a ventricular fibrillation storm in a patient supported by an Impella device after an acute coronary syndrome

“…However, it has been reported that 25% of patients who undergo catheter ablation for VF using PDN develop cLBBB. 3 …”

“… 2 However, while PDN may be relatively easy to perform, it poses a risk of complete left bundle branch block (cLBBB), as seen in a previous study where 25% of patients developed new cLBBB during PDN. 3 In this report, we describe a patient with a drug-refractory VF storm following ACS under Impella support in whom we successfully performed PDN using the ripple map (RM) feature integrated into the CARTO 3 system (Biosense Webster, Diamond Bar, CA) to identify the bifurcation of the main left bundle into the left anterior and posterior fascicles.…”

Successful ablation of Purkinje ectopy–triggered ventricular fibrillation storm in a patient with orthotopic heart transplantation and severe SARS-CoV-2 pneumonia: a case report

“…If challenging cases arise where there is an absence of trigger PVCs and low-voltage areas representing scar or fibrosis, Purkinje de-networking can be considered as an alternative. 9 , 10 …”

Successful catheter ablation of ventricular fibrillation storm in acute myocardial infarction by eliminating triggering premature ventricular contraction at the remote site from the exit

“…Recently, “Purkinje de-networking” has emerged as an optional treatment of VF. 7 The strategy proposed is to ablate all Purkinje potentials between LAF and LPF in the sense of tissue homogenization. The triggering PVC in the present case could have been treated with this technique because it is likely that the success site as well as the conducting pathway to the exit of the PVC were included within this target region.…”