Impact of the inflammation on the outcomes of catheter ablation of drug‐refractory ventricular tachycardia in cardiac sarcoidosis

Abstract

Introduction Catheter ablation (CA) of ventricular tachycardia (VT) in cardiac sarcoidosis (CS) has been reported with varying success. However, there is a scarcity of data on the outcomes of CA based on ongoing inflammation. Objective We hypothesized that the response to VT ablation depends upon the stage of the disease. Methods Between July 2004 and December 2018, 24 patients of CS presented with drug‐refractory VT at CARE Hospital (Hyderabad) and the University of Minnesota (Minneapolis, MN). Patients were classified into two groups based on cardiac magnetic resonance imaging and positron emission tomography: (a) inflammatory phase, (b) scar phase. All patients underwent 3D electro‐anatomic mapping guided CA. Results The clinical VT was ablated in all but one patient. In 16 patients (66.6%), both the clinical and nonclinical VTs were ablated (complete success), while in seven patients (29.1%) nonclinical VTs was still inducible. In patients with inflammation (group A), complete success for VT ablation was achieved in 10 out of 17 (58.8%). In patients without inflammation (group B), complete success was achieved in six out of seven patients (85.7%). Eleven patients (45.8%) had a recurrence of VT. Among patients in the inflammatory phase (group A): 10 out of 17 patients had a recurrence of VT, while only one out of seven patients in the scar phase (group B) had VT recurrence over a mean follow‐up of 5.7 ± 3.9 years. Epicardial ablation was performed in 10 (41.6%) patients. Conclusion CA of drug‐refractory VT in CS is effective, often requiring the epicardial approach. Incomplete success and recurrence of VT were higher in the inflammatory phase of the disease.

Management of ventricular tachycardia in patients with cardiac sarcoidosis

“…Muser and colleagues 34 showed that a positive baseline FDG-PET scan led to an almost 4-fold increased rate of events in follow-up, primarily VT recurrence. Similarly Kaur and colleagues 57 showed that among patients in the inflammatory phase, 10 out of 17 had a recurrence of VT (58.8%), while only 1 out of 7 patients in the scar phase had VT recurrence over a mean follow-up of 5.7 ± 3.9 years. These findings suggest the importance of optimizing steroids/IST for control of VT prior to ablation.…”

“…34 Similarly Kaur and showed that aamongst patients in the inflammatory phase 10 out of 17 patients had a recurrence of VT (58.8%), while only one out of seven patients in the scar phase had VT recurrence over a mean follow-up of 5.7 +/-3.9 years These findings suggest the importance of optimizing steroids / immunosuppressive therapy for control of ventricular tachycardia prior to ablation. 57…”

“…These findings suggest the importance of optimizing steroids/IST for control of VT prior to ablation. 57 …”

“…Likely principally related to the complex disease substrate, VT ablation is technically challenging, often requiring epicardial ablation, with modest outcomes and much remains to be learned. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 11 J o u r n a l P r e -p r o o f 20,67,68 Phase /stage of disease Absence of active inflammation 34,57 Response to immunosuppression Decreased inflammation 69 Anatomical site Absence of intramural lesions, sparing of the para-hisian region and absence of extensive RV scarring 33,70 Electrophysiological features Absence of: Multiple induced VT…”

Arrhythmias Associated with Inflammatory Cardiomyopathies

“…Although CS confers a substrate for reentrant VT, catheter ablation can be challenging due to the complexity of substrates with multiple circuits and subepicardial locations likely requiring an epicardial ablation [49][50][51][52]. Besides, catheter ablation has been shown to have a lower likelihood for acute success and a higher recurrence rate if performed in the inflammatory phase compared to the healed phase [50•].…”