Epicardial mapping and ablation of the right ventricle substrate during flecainide testing in Brugada syndrome

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

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

Kotake

Barua

Kazi

et al. 2022

Clin Res Cardiol

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Electrical Substrate Ablation for Refractory Ventricular Fibrillation

Krummen

Hoffmayer

et al. 2021

Circ: Arrhythmia and Electrophysiology

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Background - Refractory ventricular fibrillation (VF) is a challenging clinical entity, for which ablation of triggering premature ventricular complexes (PVCs) is described. When PVCs are infrequent and multifocal, the optimal treatment strategy is uncertain. Methods - We prospectively enrolled consecutive patients presenting with multiple ICD shocks for VF refractory to antiarrhythmic drug therapy, exhibiting infrequent (≤3%), multifocal PVCs (≥3 morphologies). Procedurally, VF was induced with rapid pacing and mapped, identifying sites of conduction slowing and rotation or rapid focal activation. VF electrical substrate ablation (VESA) was then performed. Outcomes were compared against reference patients with VF who were unable or unwilling to undergo catheter ablation. The primary outcome was a composite of ICD shock, electrical storm, or all-cause mortality. Results - VF was induced and mapped in 6 patients (60±10 y, LVEF 46±19%) with ischemic (n=3) and nonischemic cardiomyopathy. An average of 3.3±0.5 sites of localized reentry during VF were targeted for radiofrequency ablation (38.3±10.9 minutes) during sinus rhythm, rendering VF non-inducible with pacing. Freedom from the primary outcome was 83% in the VF ablation group versus 17% in 6 non-ablation reference patients at a median of 1.0 years (IQR 0.5-1.5 years, p=0.046) follow-up. Conclusions - VESA is associated with a reduction in the combined endpoint compared with the non-ablation reference group. Additional work is required to understand the precise pathophysiologic changes which promote VF in order to improve preventative and therapeutic strategies.

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Epicardial mapping and ablation of the right ventricle substrate during flecainide testing in Brugada syndrome

Cited by 2 publications

References 13 publications

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

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

Electrical Substrate Ablation for Refractory Ventricular Fibrillation

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