Characteristics and Outcomes of Ventricular Tachycardia and Premature Ventricular Contractions Ablation in Patients with Prior Mitral Valve Surgery

Abstract

Background: Data regarding ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation following MVS is limited.) CA can be challenging given perivalvular substrate in the setting of mitral annuloplasty or prosthetic valves. Objective: To investigate the characteristics, safety, and outcomes of radiofrequency catheter ablation (CA) in patients with prior mitral valve surgery (MVS) and ventricular arrhythmias (VA). Methods: We identified consecutive patients with prior MVS who underwent CA for VT or PVC between January 2013- December 2018. We investigated the mechanism of arrhythmia, ablation approach, peri-operative complications, and outcomes. Results: In our cohort of 31 patients (77% men, mean age 62.3±10.8 years, left ventricular ejection fraction 39.2±13.9%) with prior MVS underwent CA (16 VT; 15 PVC). Access to the left ventricle was via transseptal approach in 17 patients, and a retrograde aortic approach was used in 13 patients. A combined transseptal and retrograde aortic approach was used in one patient, and a percutaneous epicardial approach was combined with trans-septal approach in 1patient. Heterogenous scar regions were present in 94% of VT patients and scar-related reentry was the dominant mechanism of VT. Clinical VA substrates involved the peri-mitral area in 6 patients with VT and 5 patients with PVC ablation. No procedure-related complications were reported. The overall recurrence-free rate at 1-year was 72.2%; 67% in the VT group and 78% in the PVC group. No arrhythmia-related death was documented on long-term follow-up. Conclusion: CA of VAs can be performed safely and effectively in patients with MVS

Response to letter to the editor regarding “Characteristics and outcomes of ventricular tachycardia and premature ventricular contractions ablation in patients with prior mitral valve surgery”

“…">We did compare patients with coronary artery disease (CAD) to patients without CAD. As discussed in our manuscript, MVS patients with a history of CAD showed a trend of better VA recurrence‐free survival compared with those without CAD history 1 …”

“…However, our cohort is one of the least heterogeneous in the literature addressing VAs ablation in patients MVS as most prior studies evaluated arrhythmias in patients with heart surgery or valve surgery in general as discussed in the introduction section of our manuscript. 1 Although mitral regurgitation is classified into primary and secondary as proposed by the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines, different classifications and subgroups exist based on causes, mechanisms, and leaflet motion, which might cause confusion due to overlapping terminologies. 2,3 We concur that the study of VA outcomes based on the specific mechanism of mitral disease would be a welcome addition to the literature.…”

“…As discussed in our manuscript, MVS patients with a history of CAD showed a trend of better VA recurrence-free survival compared with those without CAD history. 1 3. Cardiac MRI was not routinely obtained before ablation in our cohort.…”

Mind the valve: Ventricular tachycardia ablation post‐valve interventions

“…Complications in this study were related to vascular access, with one femoral artery pseudoaneurysm requiring surgical repair, and one common iliac dissection conservatively managed. More recently, Khalil et al (2021) reported a case series of 31 patients with prior MVR undergoing ablation for VT ( n = 16) orpremature ventricular complex ( n = 15) 6 . Of the patients undergoing VT ablation, 4 had MVR and 12 had mitral valve repair.…”

“…3 Previous studies have provided some insights into the mechanisms of VT in the specific population of patients with previous valve interventions. [4][5][6] Overall, they show that the presence of voltage abnormalities and abnormal electrograms with perivalvular distribution is almost a universal finding, but these regions of fibrosis are not always responsible for the clinical VTs, which can instead be related to ischemic scars or other nonischemic processes. Although intramyocardial reentry is the predominant mechanism in these patients, bundle branch reentry has been reported in up to 10% of cases, and focal arrhythmias can also be encountered.…”