Frédéric Sacher

Outcome After Implantation of a Cardioverter-Defibrillator in Patients With Brugada Syndrome A Multicenter Study

Background— Implantable cardioverter-defibrillator indications in Brugada syndrome remain controversial, especially in asymptomatic patients. Previous outcome data are limited by relatively small numbers of patients or short follow-up durations. We report the outcome of patients with Brugada syndrome implanted with an implantable cardioverter-defibrillator in a large multicenter registry. Methods and Results— A total of 378 patients (310 male; age, 46±13 years) with a type 1 Brugada ECG pattern implanted with an implantable cardioverter-defibrillator (31 for aborted sudden cardiac arrest, 181 for syncope, and 166 asymptomatic) were included. Fifteen patients (4%) were lost to follow-up. During a mean follow-up of 77±42 months, 7 patients (2%) died (1 as a result of an inappropriate shock), and 46 patients (12%) had appropriate device therapy (5±5 shocks per patient). Appropriate device therapy rates at 10 years were 48% for patients whose implantable cardioverter-defibrillator indication was aborted sudden cardiac arrest, 19% for those whose indication was syncope, and 12% for the patients who were asymptomatic at implantation. At 10 years, rates of inappropriate shock and lead failure were 37% and 29%, respectively. Inappropriate shock occurred in 91 patients (24%; 4±4 shocks per patient) because of lead failure (n=38), supraventricular tachycardia (n=20), T-wave oversensing (n=14), or sinus tachycardia (n=12). Importantly, introduction of remote monitoring, programming a high single ventricular fibrillation zone (>210–220 bpm), and a long detection time were associated with a reduced risk of inappropriate shock. Conclusions— Appropriate therapies are more prevalent in symptomatic Brugada syndrome patients but are not insignificant in asymptomatic patients (1%/y). Optimal implantable cardioverter-defibrillator programming and follow-up dramatically reduce inappropriate shock. However, lead failure remains a major problem in this population.

Ventricular tachycardia ablation: evolution of patients and procedures over 8 years.

Background— Evolving management of coronary artery disease, heart failure, and the use of implantable cardioverter-defibrillators impacts the characteristics of patients with recurrent ventricular tachycardia (VT). We investigated the substrate, procedure, and outcome evolution of all patients referred for VT ablation during the past 8 years. Methods and Results— From 1999 to 2006, 493 consecutive patients (358 male, 57±16 years) underwent 623 VT ablations: 131 had no structural heart disease (SHD), 213 had ischemic cardiomyopathies (ICMP), and 149 had nonischemic cardiomyopathies (NICMP). Although the main substrate is ICMP, the proportion of NICMP has increased from 27% to 35% (P=0.06) from 1999–2002 to the 2003–2006. The procedure abolished or modified inducible VTs in ≥75% of patients in all groups, but abolition of all monomorphic VTs was achieved in 125 (83%) patients without SHD, 180 (65%) with ICMP, and 99 (51%) with NICMP (P<0.0001). During a mean follow-up of 3.3±2.4 years, no deaths occurred in patients without SHD, but 75 patients (35%) with ICMP and 26 patients (17%) with NICMP died after a median of 13 months. Multivariate Cox regression analysis found that age, ejection fraction, and need for preprocedural mechanical hemodynamic support predicted mortality. Conclusions— The substrate causing VT in patients requiring ablation is evolving and determines the long-term outcome. In the setting of a normal heart, VT ablation is associated with a low risk of subsequent mortality, with no deaths occurring during a mean follow-up of >3 years. In contrast, in patients with SHD and recurrent VT, VT ablation can be helpful to suppress drug refractory VT, but long-term mortality remains significant.Background— Evolving management of coronary artery disease, heart failure, and the use of implantable cardioverter-defibrillators impacts the characteristics of patients with recurrent ventricular tachycardia (VT). We investigated the substrate, procedure, and outcome evolution of all patients referred for VT ablation during the past 8 years.nnMethods and Results— From 1999 to 2006, 493 consecutive patients (358 male, 57±16 years) underwent 623 VT ablations: 131 had no structural heart disease (SHD), 213 had ischemic cardiomyopathies (ICMP), and 149 had nonischemic cardiomyopathies (NICMP). Although the main substrate is ICMP, the proportion of NICMP has increased from 27% to 35% ( P =0.06) from 1999–2002 to the 2003–2006. The procedure abolished or modified inducible VTs in ≥75% of patients in all groups, but abolition of all monomorphic VTs was achieved in 125 (83%) patients without SHD, 180 (65%) with ICMP, and 99 (51%) with NICMP ( P <0.0001). During a mean follow-up of 3.3±2.4 years, no deaths occurred in patients without SHD, but 75 patients (35%) with ICMP and 26 patients (17%) with NICMP died after a median of 13 months. Multivariate Cox regression analysis found that age, ejection fraction, and need for preprocedural mechanical hemodynamic support predicted mortality.nnConclusions— The substrate causing VT in patients requiring ablation is evolving and determines the long-term outcome. In the setting of a normal heart, VT ablation is associated with a low risk of subsequent mortality, with no deaths occurring during a mean follow-up of >3 years. In contrast, in patients with SHD and recurrent VT, VT ablation can be helpful to suppress drug refractory VT, but long-term mortality remains significant.nnReceived January 28, 2008; accepted May 1, 2008.

The Early Repolarization Pattern

The term early repolarization has been in use for more than 50 years. This electrocardiographic pattern was considered benign until 2008, when it was linked to sudden cardiac arrest due to idiopathic ventricular fibrillation. Much confusion over the definition of early repolarization followed. Thus, the objective of this paper was to prepare an agreed definition to facilitate future research in this area. The different definitions of the early repolarization pattern were reviewed to delineate the electrocardiographic measures to be used when defining this pattern. An agreed definition has been established, which requires the peak of an end-QRS notch and/or the onset of an end-QRS slur as a measure, denoted Jp, to be determined when an interpretation of early repolarization is being considered. One condition for early repolarization to be present is Jpxa0≥0.1 mV, while ST-segment elevation is not a required criterion.

J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge

The J-wave syndromes (JWSs), consisting of the Brugada syndrome (BrS) and early repolarization syndrome (ERS), have captured the interest of the cardiology community over the past 2 decades following the identification of BrS as a new clinical entity by Pedro and Josep Brugada in 1992.[1][1] The

Transcoronary ethanol ventricular tachycardia ablation in the modern electrophysiology era.

BACKGROUNDnRadiofrequency catheter ablation for ventricular tachycardia (VT) may be unsuccessful when critical portions of the circuit cannot be interrupted with either endocardial or epicardial radiofrequency application.nnnOBJECTIVEnWe sought to investigate whether transcoronary ethanol ablation (TCEA) can be used as a therapy for patients with VT who have failed medications and radiofrequency ablation in the modern era.nnnMETHODSnNine patients (7 men, 55 +/- 9 years old, left ventricular ejection fraction 23% +/- 8%, 2.2 +/- 0.8 failed VT ablations) with at least 1 unsuccessful attempt at radiofrequency catheter ablation for symptomatic VT at our institution between 2000 and May 2007 underwent TCEA. The majority of patients had an ischemic cardiomyopathy (67%), and all patients had VT due to scar-related reentry. In the 7 patients with VT involving a septal scar, a septal perforator artery was a suitable target in 5 patients, whereas in the remaining patients, a distal branch of the circumflex and the conus branch of the right coronary artery were targeted. In the 2 patients in whom VT involved an inferior scar, a branch of the posterior descending artery was targeted.nnnRESULTSnAcute success was obtained in 56% of patients (89% for clinical targeted VT). During a mean follow-up of 29 +/- 23 months, 3 deaths occurred and 67% of the patients were free of recurrence.nnnCONCLUSIONnTCEA may represent an option in patients with refractory VT in whom radiofrequency ablation fails, especially in cases of septal scar in which failure is thought to be caused by inability to provide adequate lesion depth.

Transcoronary Ethanol Ablation for Recurrent Ventricular Tachycardia After Failed Catheter Ablation An Update

Background— Despite substantial progress, radiofrequency catheter ablation (RFCA) fails in some patients. After encouraging results with transcoronary ethanol ablation (TCEA), we began offering TCEA routinely when endocardial and epicardial RFCA failed or a deep intramural substrate was likely. Methods and Results— Among 274 consecutive patients who underwent 408 ventricular tachycardia (VT) ablation procedures, 27 patients (21 men; age, 63±13 years; left ventricular ejection fraction, 30±11%; ischemic cardiomyopathy, 14) had 29 TCEA procedures attempted. In 5 patients, TCEA was abandoned because of unfavorable anatomy. In 22 patients, a mean of 1.3±0.6 arteries (range, 1–3 arteries) were targeted for TCEA. After ablation, the targeted VT was no longer inducible in 18 of 22 (82%) patients. Complete heart block occurred in 5 patients, and 3 patients with advanced heart failure died within 30 days of the procedure. After the last TCEA procedure, a VT recurred in 64% of patients, and overall, 32% of patients died. Of 11 patients with prior VT storm, 9 were free of VT storm. At repeat study in 8 patients who had a recurrence, 7 had a new QRS morphology of VT originating from the same general substrate region as the prior VT. Conclusions— In patients with difficult-to-control VT in whom RFCA fails, TCEA prevents all VT recurrences in 36% and improves arrhythmia control in an additional 27%. Inadequate target vessels, collaterals, and recurrence of modified VTs limit efficacy, but TCEA continues to play an important role for difficult VTs in these high-risk patients.

Ventricular Tachycardia AblationCLINICAL PERSPECTIVE

Background— Evolving management of coronary artery disease, heart failure, and the use of implantable cardioverter-defibrillators impacts the characteristics of patients with recurrent ventricular tachycardia (VT). We investigated the substrate, procedure, and outcome evolution of all patients referred for VT ablation during the past 8 years. Methods and Results— From 1999 to 2006, 493 consecutive patients (358 male, 57±16 years) underwent 623 VT ablations: 131 had no structural heart disease (SHD), 213 had ischemic cardiomyopathies (ICMP), and 149 had nonischemic cardiomyopathies (NICMP). Although the main substrate is ICMP, the proportion of NICMP has increased from 27% to 35% (P=0.06) from 1999–2002 to the 2003–2006. The procedure abolished or modified inducible VTs in ≥75% of patients in all groups, but abolition of all monomorphic VTs was achieved in 125 (83%) patients without SHD, 180 (65%) with ICMP, and 99 (51%) with NICMP (P<0.0001). During a mean follow-up of 3.3±2.4 years, no deaths occurred in patients without SHD, but 75 patients (35%) with ICMP and 26 patients (17%) with NICMP died after a median of 13 months. Multivariate Cox regression analysis found that age, ejection fraction, and need for preprocedural mechanical hemodynamic support predicted mortality. Conclusions— The substrate causing VT in patients requiring ablation is evolving and determines the long-term outcome. In the setting of a normal heart, VT ablation is associated with a low risk of subsequent mortality, with no deaths occurring during a mean follow-up of >3 years. In contrast, in patients with SHD and recurrent VT, VT ablation can be helpful to suppress drug refractory VT, but long-term mortality remains significant.Background— Evolving management of coronary artery disease, heart failure, and the use of implantable cardioverter-defibrillators impacts the characteristics of patients with recurrent ventricular tachycardia (VT). We investigated the substrate, procedure, and outcome evolution of all patients referred for VT ablation during the past 8 years.nnMethods and Results— From 1999 to 2006, 493 consecutive patients (358 male, 57±16 years) underwent 623 VT ablations: 131 had no structural heart disease (SHD), 213 had ischemic cardiomyopathies (ICMP), and 149 had nonischemic cardiomyopathies (NICMP). Although the main substrate is ICMP, the proportion of NICMP has increased from 27% to 35% ( P =0.06) from 1999–2002 to the 2003–2006. The procedure abolished or modified inducible VTs in ≥75% of patients in all groups, but abolition of all monomorphic VTs was achieved in 125 (83%) patients without SHD, 180 (65%) with ICMP, and 99 (51%) with NICMP ( P <0.0001). During a mean follow-up of 3.3±2.4 years, no deaths occurred in patients without SHD, but 75 patients (35%) with ICMP and 26 patients (17%) with NICMP died after a median of 13 months. Multivariate Cox regression analysis found that age, ejection fraction, and need for preprocedural mechanical hemodynamic support predicted mortality.nnConclusions— The substrate causing VT in patients requiring ablation is evolving and determines the long-term outcome. In the setting of a normal heart, VT ablation is associated with a low risk of subsequent mortality, with no deaths occurring during a mean follow-up of >3 years. In contrast, in patients with SHD and recurrent VT, VT ablation can be helpful to suppress drug refractory VT, but long-term mortality remains significant.nnReceived January 28, 2008; accepted May 1, 2008.

Programmed ventricular stimulation for risk stratification in the Brugada syndrome: A pooled analysis

Background— The role of programmed ventricular stimulation in identifying patients with Brugada syndrome at the highest risk for sudden death is uncertain. Methods and Results— We performed a systematic review and pooled analysis of prospective, observational studies of patients with Brugada syndrome without a history of sudden cardiac arrest who underwent programmed ventricular stimulation. We estimated incidence rates and relative hazards of cardiac arrest or implantable cardioverter-defibrillator shock. We analyzed individual-level data from 8 studies comprising 1312 patients who experienced 65 cardiac events (median follow-up, 38.3 months). A total of 527 patients were induced into arrhythmias with up to triple extrastimuli. Induction was associated with cardiac events during follow-up (hazard ratio, 2.66; 95% confidence interval [CI], 1.44–4.92, P<0.001), with the greatest risk observed among those induced with single or double extrastimuli. Annual event rates varied substantially by syncope history, presence of spontaneous type 1 ECG pattern, and arrhythmia induction. The lowest risk occurred in individuals without syncope and with drug-induced type 1 patterns (0.23%, 95% CI, 0.05–0.68 for no induced arrhythmia with up to double extrastimuli; 0.45%, 95% CI, 0.01–2.49 for induced arrhythmia), and the highest risk occurred in individuals with syncope and spontaneous type 1 patterns (2.55%, 95% CI, 1.58–3.89 for no induced arrhythmia; 5.60%, 95% CI, 2.98–9.58 for induced arrhythmia). Conclusions— In patients with Brugada syndrome, arrhythmias induced with programmed ventricular stimulation are associated with future ventricular arrhythmia risk. Induction with fewer extrastimuli is associated with higher risk. However, clinical risk factors are important determinants of arrhythmia risk, and lack of induction does not necessarily portend low ventricular arrhythmia risk, particularly in patients with high-risk clinical features.

J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge☆☆☆

J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge Charles Antzelevitch, PhD, FHRS, Gan-Xin Yan, MD, PhD, Michael J. Ackerman, MD, PhD, Martin Borggrefe, MD, Domenico Corrado, MD, PhD, Jihong Guo, MD, Ihor Gussak, MD, PhD, Can Hasdemir, MD, Minoru Horie, MD, Heikki Huikuri, MD, Changsheng Ma, MD, Hiroshi Morita, MD, PhD, Gi-Byoung Nam, MD, PhD, Frederic Sacher, MD, PhD, Wataru Shimizu, MD, PhD, Sami Viskin, MD, Arthur A.M. Wilde, MD, PhD, FHRS

Prevalence, characteristics, and prognosis role of type 1 ST elevation in the peripheral ECG leads in patients with Brugada syndrome

BACKGROUNDnDespite isolated reports of Brugada syndrome (BrS) in the inferior or lateral leads, the prevalence and prognostic value of ST elevation in the peripheral electrocardiographic (ECG) leads in patients with BrS remain poorly known.nnnOBJECTIVEnTo study the prevalence, characteristics, and prognostic value of type 1 ST elevation and ST depression in the peripheral ECG leads in a large cohort of patients with BrS.nnnMETHODSnECGs from 323 patients with BrS (age 47 ± 13 years; 257 men) with spontaneous (n = 141) or drug-induced (n = 182) type 1 ECG were retrospectively reviewed. Two hundred twenty-five (70%) patients were asymptomatic, 72 (22%) patients presented with unexplained syncope, and 26 (8%) patients presented with sudden death (12 patients) or appropriated implantable cardioverter-defibrillator therapies (14 patients) at diagnosis or over a mean follow-up of 48 ± 34 months.nnnRESULTSnThirty (9%) patients presented with type 1 ST elevation in at least 1 peripheral lead (22 patients in the aVR leads, 2 in the inferior leads, 5 in both aVR and inferior leads, and 1 in the aVR and VL leads). Patients with type 1 ST elevation in the peripheral leads more often had mutations in the SCN5A gene, were more often inducible, had slower heart rate, and higher J-wave amplitude in the right precordial leads. Twenty-seven percent (8 of 30) of the patients with type 1 ST elevation in the peripheral leads experimented sudden death/appropriate implantable cardioverter-defibrillator therapy, whereas it occurred in only 6% (18 of 293) of other patients (P < .0001). In multivariate analysis, type 1 ECG in the peripheral leads was independently associated with malignant arrhythmic events (odds ratio 4.58; 95% confidence interval 1.7-12.32; P = .0025).nnnCONCLUSIONSnType 1 ST elevation in the peripheral ECG leads can be seen in 10% of the patients with BrS and is an independent predictor for a malignant arrhythmic event.