Epicardial Brugada syndrome ablation unmasking inferior J waves

Abstract

Patients with Brugada syndrome are at risk of life-threatening ventricular arrhythmias. Epicardial substrate ablation for Brugada syndrome has been described as a means of controlling these arrhythmias and recent reports describe elimination of the Brugada phenotype with ablation. We describe a unique case in which a patient developed inferior J waves with an early repolarization-type electrocardiogram following successful epicardial infundibular substrate ablation (which eliminated the Brugada syndrome electrocardiogram on ajmaline challenge). We discuss the likely underlying pathophysiology responsible for this phenomenon, its relationship to the anatomic obstacles encountered during epicardial ablation, and the implications for long-term arrhythmic risk.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

“…Given the potential presence of significant epicardial fat, low voltage in isolation is not indicative of underlying substrate. Caudal extension of the substrate has been associated with the presence of concomitant inferolateral J waves and early repolarization syndrome ( S9.8.6.31 , S9.8.6.32 ).…”

“…The most important factor in this regard is the relationship of the surrounding at-risk structures. Although the phrenic nerve is not usually a consideration, the proximal large subdivisions of the right coronary artery are potentially at risk, particularly the conus branch and the RV marginal arteries ( S9.8.6.32 ). Ablation-induced acute occlusion of the former could potentially result in VF, and injury to the latter risks infarction of an otherwise normally contractile RV.…”

The dividing line of arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome at epicardial ablation era: Limited to or beyond RVOT?

“…This distinction is also important in the understanding of correlation between the extension of substrate and electrocardiographic findings . Type 1 ST elevation in the peripheral ECG leads can be seen in 10% of the patients with BrS .…”

Substrate ablation for post-infarct and Brugada storm: Triggering the calm

“…A particular consideration in Brugada syndrome that has received scant attention in the literature is the relationship of the RV epicardial coronary arteries to the common substrate locations. In a recent published case, sizeable conus and RV marginal branches precluded safe elimination of the entirety of the substrate, although enough ablation had been performed to abolish the Brugada ECG pattern on ajmaline challenge 9 . Further systematic examination of this question is urgently warranted given the greater exposure of increasingly less symptomatic, non-ES patients to epicardial substrate ablation in Brugada syndrome 10 .…”