Efficacy and safety of catheter ablation for Brugada syndrome: an updated systematic review

Abstract

Background Patients with Brugada syndrome (BrS) may experience recurrent ventricular arrhythmias (VAs). Catheter ablation is becoming an emerging paradigm for treatment of BrS. Objective To assess the efficacy and safety of catheter ablation in BrS in an updated systematic review. Methods We comprehensively searched the databases of Pubmed/Medline, EMBASE, and Cochrane Central Register of Controlled Trials from inception to 11th of August 2021. Results Fifty-six studies involving 388 patients were included. A substrate-based strategy was used in 338 cases (87%), and a strategy of targeting premature ventricular complex (PVCs)/ventricular tachycardias (VTs) that triggered ventricular fibrillation (VF) in 47 cases (12%), with combined abnormal electrogram and PVC/VT ablation in 3 cases (1%). Sodium channel blocker was frequently used to augment the arrhythmogenic substrate in 309/388 cases (80%), which included a variety of agents, of which ajmaline was most commonly used. After ablation procedure, the pooled incidence of non-inducibility of VA was 87.1% (95% confidence interval [CI], 73.4–94.3; I2 = 51%), and acute resolution of type I ECG was seen in 74.5% (95% CI [52.3–88.6]; I2 = 75%). Over a weighted mean follow up of 28 months, 7.6% (95% CI [2.1–24]; I2 = 67%) had recurrence of type I ECG either spontaneously or with drug challenge and 17.6% (95% CI [10.2–28.6]; I2 = 60%) had recurrence of VA. Conclusion Catheter ablation appears to be an efficacious strategy for elimination of arrhythmias or substrate associated with BrS. Further study is needed to identify which patients stand to benefit, and optimal provocation protocol for identifying ablation targets. Graphical abstract

High-risk Brugada syndrome: factors associated with arrhythmia recurrence and benefits of epicardial ablation in addition to implantable cardioverter defibrillator implantation

“…Despite its complex and invasive nature necessitating general anaesthesia, this study demonstrates a favourable safety profile for epicardial ablation. Major complications were rare, consistent with previous studies from experienced centres, 5–9 , 13–15 , 24 but widespread adoption of this complex procedure could carry certain risks, and selection of patients is indeed crucial. Notably, the safety of the ajmaline test, especially the initial test with the substrate remaining intact, holds paramount significance.…”

“…Positive outcomes from epicardial substrate ablation in high-risk symptomatic BrS populations, as documented in previous studies, have been marred by several limitations. 9 , 13–15 , 23 , 24 These include varying learning curves across centres, diverse sample sizes, treatment heterogeneity, a range of mapping/ablation protocols potentially impacting substrate identification and ablation efficiency, variable follow-up durations, different data collection methodologies, and notably, a lack of control groups. We aimed to address these constraints by adopting a uniform mapping/ablation technique, utilizing ajmaline infusion, consistent long-term follow-ups, and introducing a no-RFA group for a thorough analysis.…”

Trigger and Substrate Mapping and Ablation for Ventricular Fibrillation in the Structurally Normal Heart

“…A recent systematic review of ablation in BrS found that in 388 patients, VF was non-inducible in 87.1% of patients after ablation, and resolution of type 1 ECG was seen in 74.5% [66]. Recurrent VA was seen in 17.6%.…”