Serge A. Trines

The Atrial Fibrillation Ablation Pilot Study: an European Survey on Methodology and results of catheter ablation for atrial fibrillation conducted by the European Heart Rhythm Association

AIMSnThe Atrial Fibrillation Ablation Pilot Study is a prospective registry designed to describe the clinical epidemiology of patients undergoing an atrial fibrillation (AFib) ablation, and the diagnostic/therapeutic processes applied across Europe. The aims of the 1-year follow-up were to analyse how centres assess in routine clinical practice the success of the procedure and to evaluate the success rate and long-term safety/complications.nnnMETHODS AND RESULTSnSeventy-two centres in 10 European countries were asked to enrol 20 consecutive patients undergoing a first AFib ablation procedure. A web-based case report form captured information on pre-procedural, procedural, and 1-year follow-up data. Between October 2010 and May 2011, 1410 patients were included and 1391 underwent an AFib ablation (98.7%). A total of 1300 patients (93.5%) completed a follow-up control 367 ± 42 days after the procedure. Arrhythmia documentation was done by an electrocardiogram in 76%, Holter-monitoring in 52%, transtelephonic monitoring in 8%, and/or implanted systems in 4.5%. Over 50% became asymptomatic. Twenty-one per cent were re-admitted due to post-ablation arrhythmias. Success without antiarrhythmic drugs was achieved in 40.7% of patients (43.7% in paroxysmal AF; 30.2% in persistent AF; 36.7% in long-lasting persistent AF). A second ablation was required in 18% of the cases and 43.4% were under antiarrhythmic treatment. Thirty-three patients (2.5%) suffered an adverse event, 272 (21%) experienced a left atrial tachycardia, and 4 patients died (1 haemorrhagic stroke, 1 ventricular fibrillation in a patient with ischaemic heart disease, 1 cancer, and 1 of unknown cause).nnnCONCLUSIONnThe AFib Ablation Pilot Study provided crucial information on the epidemiology, management, and outcomes of catheter ablation of AFib in a real-world setting. The methods used to assess the success of the procedure appeared at least suboptimal. Even in this context, the 12-month success rate appears to be somewhat lower to the one reported clinical trials.

Outcome of Ventricular Tachycardia Ablation in Patients with Nonischemic Cardiomyopathy: The Impact of Noninducibility

Background—Ablation failure and recurrence rates after ventricular tachycardia (VT) ablation in nonischemic cardiomyopathy are high and the optimal procedural end point is not well defined. This study assessed the outcome after ablation, the impact of noninducibility, and other potential predictors of VT recurrence. Methods and Results—Forty-five patients with nonischemic cardiomyopathy (60±16 years; left ventricular ejection fraction, 44±14%) accepted for VT ablation were included. Epicardial mapping was performed in 29 (64%). A median of 2 (first-to-third quartile, 2–4) VTs (cycle length, 342±77 ms) were induced per patient. After ablation, the complete programmed electric stimulation protocol (3 drive cycle length, 3 extrastimuli ≥200 ms, and burst≥2 sites) was repeated. Complete success (noninducibility of any monomorphic VT) was achieved in 17 patients (38%), partial success (elimination of clinical VT, persistent inducibility of nonclinical VT) in 17 patients (38%), and failure (persistent inducibility of clinical VT) in 11 patients (24%). During 25±15 months of follow-up, VT occurred in 24 patients (53%), but the 6-month VT burden was reduced by ≥75% in 79%. Recurrence rates were low after complete procedural success (18%), but high after both partial success (77%) and failure (73%). Non-complete procedural success was the strongest predictor of VT recurrence (hazard ratio, 8.20; 95% confidence interval, 2.37–28.43; P=0.001). Conclusions—Although 53% of patients had VT during follow-up, the 6-month VT burden was decreased by ≥75% in 79%. Recurrence rates are low after complete procedural success, but high after both partial success and failure. Non-complete procedural success was the strongest predictor of VT recurrence.

Reassessing noninducibility as ablation endpoint of post-infarction ventricular tachycardia: the impact of left ventricular function.

Background—Noninducibility is frequently used as procedural end point of ventricular tachycardia (VT) ablation after myocardial infarction. We investigated the influence of left ventricular (LV) function on the predictive value of noninducibility for VT recurrence and cardiac mortality. Methods and Results—Ninety-one patients (82 men, 67±10 years) with post–myocardial infarction VT underwent ablation between 2009 and 2012. Fifty-nine (65%) had an LV ejection fraction (EF) >30% (mean 41±7) and 32 (35%) an LVEF⩽30% (mean 20±5). Thirty patients (51%) with EF>30% and 13 (41%) with EF⩽30% were noninducible after ablation (P=0.386). During a median follow-up of 23 (Q1–Q3 16–36) months, 35 patients (38%) experienced VT recurrences and 17 (18%) cardiac death. At 1 year follow-up, survival free from VT recurrence and cardiac death for patients with LVEF>30% was 80% (95% confidence interval [CI], 70–90) compared with 42% (95% CI, 33–51) for those with LVEF⩽30% (P=0.001). Noninducible patients with LVEF>30% had a recurrence-free survival from cardiac death of 90% (95% CI, 71–100) compared with 65% (95% CI, 47–83) for inducible patients (P=0.015). In the subgroup of patients with LVEF⩽30%, the survival free from VT recurrence and cardiac death was 31% (95% CI, 0%–60%) for noninducible compared with 39% (95% CI, 27–52) for those who remained inducible (P=0.842). Conclusions—Noninducible patients with moderately depressed LV function have a favorable outcome compared with patients who remained inducible after ablation. On the contrary, patients with severely depressed LV function have a poor prognosis independent of the acute procedural outcome.

Endocardial or epicardial ventricular tachycardia in nonischemic cardiomyopathy? The role of 12-lead ECG criteria in clinical practice.

BACKGROUNDnSpecific 12-lead ECG criteria have been reported to predict an epicardial site of origin (SoO) of induced ventricular tachycardias (VTs) in left ventricular nonischemic cardiomyopathy.nnnOBJECTIVEnThe purpose of this study was to (1) determine the value of ECG criteria to predict an epicardial SoO of clinically documented VTs, (2) analyze the effect of VT cycle length (CL) and antiarrhythmic drugs on the accuracy of ECG criteria, and (3) assess interobserver variability.nnnMETHODSnIn 36 consecutive patients with nonischemic left ventricular cardiomyopathy (age 58 ± 16 years, 75% male) who underwent combined endocardial/epicardial VT ablation, all clinically documented and induced right bundle branch block VTs were analyzed for previously reported ECG criteria to determine the SoO, as defined by ≥11/12 pace-map, concealed entrainment, and/or VT termination during ablation.nnnRESULTSnIn 21 patients with clinically documented (25 mm/s) right bundle branch block VT, none of the ECG criteria differentiated between patients with and those without an epicardial SoO. In induced VTs (100 mm/s), 2 of 4 interval criteria differentiated between an endocardial and epicardial SoO for slow VTs (CL >350 ms) and 2 of 4 criteria in patients on amiodarone, but none for fast VTs (CL ≤350 ms) or patients off amiodarone. The Q wave in lead I was the most accurate criterion for an epicardial SoO (sensitivity 88%, specificity 80%). In both clinically documented and induced VTs, interobserver agreement was poor for pseudodelta wave and moderate for other criteria.nnnCONCLUSIONnWhen applied to clinically documented VTs, no ECG criterion could differentiate between patients with and those without an epicardial SoO. Published interval-based ECG criteria do not apply to fast VTs and patients off amiodarone.

Fast nonclinical ventricular tachycardia inducible after ablation in patients with structural heart disease: Definition and clinical implications

BACKGROUNDnNoninducibility of ventricular tachycardia (VT) with an equal or longer cycle length (CL) than that of the clinical VT is considered the minimum ablation endpoint in patients with structural heart disease. Because their clinical relevance remains unclear, fast nonclinical VTs are often not targeted. However, an accepted definition for fast VT is lacking. The shortest possible CL of a monomorphic reentrant VT is determined by the ventricular refractory period (VRP).nnnOBJECTIVEnThe purpose of this study was to propose a patient-specific definition for fast VT based on the individual VRP (fVTVRP) and assess the prognostic significance of persistent inducibility after ablation of fVTVRP for VT recurrence.nnnMETHODSnOf 191 patients with previous myocardial infarction or with nonischemic cardiomyopathy undergoing VT ablation, 70 (age 63 ± 13 years; 64% ischemic) remained inducible for a nonclinical VT and composed the study population. FVTVRP was defined as any VT with CL ≤VRP400 + 30 ms. Patients were followed for VT recurrence.nnnRESULTSnAfter ablation, 30 patients (43%) remained inducible exclusively for fVTVRP and 40 (57%) for any slower VT. Patients with only fVTVRP had 3-year VT-free survival of 64% (95% confidence interval [CI] 46%-82%) compared to 27% (95% CI 14%-48%) for patients with any slower remaining VT (P = .013). Inducibility of only fVTVRP was independently associated with lower VT recurrence (hazard ratio 0.38; 95% CI 0.19-0.86; P = .019). Among 36 patients inducible for any fVTVRP, only 1 had recurrence with fVTVRP.nnnCONCLUSIONnIn patients with structural heart disease, inducibility of exclusively fVTVRP after ablation is associated with low VT recurrence.

Death after ablation of atrial flutter: are we doing the right thing?

This editorial refers to ‘Death and thrombo-embolic risk after ablation of atrial flutter compared with atrial fibrillation: a nationwide cohort study’ by H. Vadmann et al ., doi:10.1093/europace/euw107. nnIsolated typical right atrial flutter is a relatively uncommon arrhythmia compared with atrial fibrillation (AF) with an incidence of 88 per 100 000 person-years.1 Because of the high symptomatic burden, ablation is usually performed as a first-line therapy with a low complication rate and excellent results.2,3 In addition, long-term survival has been reported to be higher following flutter ablation than in patients with other atrial tachyarrhythmias not undergoing ablation.4 Therefore, operators generally have a low threshold in performing ablation for typical flutter.nnInterestingly and in contrast to this, Vadmann et al. 5 reported in this issue of EP-Europace that mortality was higher after ablation of atrial flutter compared with ablation of AF. They extracted data on all patients undergoing atrial flutter or AF ablation between 2000 and 2013 from the Danish national health registries based on ICD-10 codes and mortality …

Outcome of Ventricular Tachycardia Ablation in Patients With Nonischemic CardiomyopathyClinical Perspective: The Impact of Noninducibility

Background—Ablation failure and recurrence rates after ventricular tachycardia (VT) ablation in nonischemic cardiomyopathy are high and the optimal procedural end point is not well defined. This study assessed the outcome after ablation, the impact of noninducibility, and other potential predictors of VT recurrence. Methods and Results—Forty-five patients with nonischemic cardiomyopathy (60±16 years; left ventricular ejection fraction, 44±14%) accepted for VT ablation were included. Epicardial mapping was performed in 29 (64%). A median of 2 (first-to-third quartile, 2–4) VTs (cycle length, 342±77 ms) were induced per patient. After ablation, the complete programmed electric stimulation protocol (3 drive cycle length, 3 extrastimuli ≥200 ms, and burst≥2 sites) was repeated. Complete success (noninducibility of any monomorphic VT) was achieved in 17 patients (38%), partial success (elimination of clinical VT, persistent inducibility of nonclinical VT) in 17 patients (38%), and failure (persistent inducibility of clinical VT) in 11 patients (24%). During 25±15 months of follow-up, VT occurred in 24 patients (53%), but the 6-month VT burden was reduced by ≥75% in 79%. Recurrence rates were low after complete procedural success (18%), but high after both partial success (77%) and failure (73%). Non-complete procedural success was the strongest predictor of VT recurrence (hazard ratio, 8.20; 95% confidence interval, 2.37–28.43; P=0.001). Conclusions—Although 53% of patients had VT during follow-up, the 6-month VT burden was decreased by ≥75% in 79%. Recurrence rates are low after complete procedural success, but high after both partial success and failure. Non-complete procedural success was the strongest predictor of VT recurrence.

Outcome of Ventricular Tachycardia Ablation in Patients With Nonischemic CardiomyopathyClinical Perspective

Background—Ablation failure and recurrence rates after ventricular tachycardia (VT) ablation in nonischemic cardiomyopathy are high and the optimal procedural end point is not well defined. This study assessed the outcome after ablation, the impact of noninducibility, and other potential predictors of VT recurrence. Methods and Results—Forty-five patients with nonischemic cardiomyopathy (60±16 years; left ventricular ejection fraction, 44±14%) accepted for VT ablation were included. Epicardial mapping was performed in 29 (64%). A median of 2 (first-to-third quartile, 2–4) VTs (cycle length, 342±77 ms) were induced per patient. After ablation, the complete programmed electric stimulation protocol (3 drive cycle length, 3 extrastimuli ≥200 ms, and burst≥2 sites) was repeated. Complete success (noninducibility of any monomorphic VT) was achieved in 17 patients (38%), partial success (elimination of clinical VT, persistent inducibility of nonclinical VT) in 17 patients (38%), and failure (persistent inducibility of clinical VT) in 11 patients (24%). During 25±15 months of follow-up, VT occurred in 24 patients (53%), but the 6-month VT burden was reduced by ≥75% in 79%. Recurrence rates were low after complete procedural success (18%), but high after both partial success (77%) and failure (73%). Non-complete procedural success was the strongest predictor of VT recurrence (hazard ratio, 8.20; 95% confidence interval, 2.37–28.43; P=0.001). Conclusions—Although 53% of patients had VT during follow-up, the 6-month VT burden was decreased by ≥75% in 79%. Recurrence rates are low after complete procedural success, but high after both partial success and failure. Non-complete procedural success was the strongest predictor of VT recurrence.