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Zeppenfeld K, Kimura Y, Ebert M. Mapping and Ablation of Ventricular Tachycardia in Inherited Left Ventricular Cardiomyopathies. JACC Clin Electrophysiol 2023:S2405-500X(23)00816-2. [PMID: 38127011 DOI: 10.1016/j.jacep.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 12/23/2023]
Abstract
Advances in the field of human genetics have led to an accumulating understanding of the genetic basis of distinct nonischemic cardiomyopathies associated with ventricular tachycardias (VTs) and sudden cardiac death. To date, there is an increasing proportion of patients with inherited cardiomyopathies requiring catheter ablation for VTs. This review provides an overview of disease-causing gene mutations frequently encountered and relevant for clinical electrophysiologists. Available data on VT ablation in patients with an inherited etiology and a phenotype of a nondilated left ventricular cardiomyopathy, dilated cardiomyopathy, or hypertrophic cardiomyopathy are summarized. VTs amenable to catheter ablation are related to nonischemic fibrosis. Recent insights into genotype-phenotype relations of subtype and location of fibrosis have important implications for treatment planning. Current strategies to delineate nonischemic fibrosis and related arrhythmogenic substrates using multimodal imaging, image integration, and electroanatomical mapping are provided. The ablation approach depends on substrate location and extension. Related procedural aspects including patient-tailored (enhanced) ablation strategies and outcomes are outlined. Challenging substrates for VT and the underlying inherited etiologies with a high risk for rapid progressive heart failure contribute to poor outcomes after catheter ablation. Electroanatomical data obtained during ablation may allow the identification of patients at particular risk who need to be considered for early work-up for left ventricular assist device implantation or heart transplantation.
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Affiliation(s)
- Katja Zeppenfeld
- Department of Cardiology, Heart-Lung-Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark.
| | - Yoshitaka Kimura
- Department of Cardiology, Heart-Lung-Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark
| | - Micaela Ebert
- Department of Cardiology, Heart-Lung-Center, Leiden University Medical Center, Leiden, the Netherlands; Division of Electrophysiology, Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
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Segev A, Wasserstrum Y, Arad M, Larrañaga-Moreira JM, Martinez-Veira C, Barriales-Villa R, Sabbag A. Ventricular arrhythmias in patients with hypertrophic cardiomyopathy: Prevalence, distribution, predictors, and outcome. Heart Rhythm 2023; 20:1385-1392. [PMID: 37385464 DOI: 10.1016/j.hrthm.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) carries an increased risk of sudden cardiac death. Ventricular fibrillation (VF) is thought to be the common culprit arrhythmia. OBJECTIVE The purpose of this study was to describe the incidence and predictors of sustained ventricular arrhythmias (VTAs) in HCM patients. METHODS We retrospectively analyzed all patients with HCM and an implantable cardioverter-defibrillator (ICD) from a prospectively derived registry in 2 tertiary medical centers. Clinical, electrocardiographic, echocardiographic, ICD interrogation, and genetic data were collected and compared, first between patients with and without VTAs and then between patients with only VF and those with ventricular tachycardia (VT) with or without VF. RESULTS Of the 1328 HCM patients, 207 (145 [70%] male; mean age 33 ± 16 years) were implanted with ICDs. Over a mean follow-up of 10 ± 6 years, 37 patients with ICDs (18%) developed sustained VTAs. These were associated with a family history of sudden cardiac death and a personal history of VTAs (P = .036 and P = .001, respectively). Sustained monomorphic VT was the most common arrhythmia (n = 26, 70%) and was linked to decreased left ventricular (LV) ejection fraction and increased LV end-systolic and end-diastolic diameters. Antitachycardia pacing (ATP) successfully terminated 258 (79%) of the 326 VT events. Mortality rates were comparable between patients with and without VTAs (4 [11%] vs 29 [17%]; P = .42) and between those with and without ICDs (24 [16%] vs 85 [20%]; P = .367). CONCLUSION VT rather than VF is the most common arrhythmia in patients with HCM; it is amenable to ATP and is associated with lower LV ejection fraction and higher LV diameters. Therefore, ATP-capable devices may be considered in HCM patients with these LV features.
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MESH Headings
- Humans
- Male
- Adolescent
- Young Adult
- Adult
- Middle Aged
- Female
- Retrospective Studies
- Prevalence
- Tachycardia, Ventricular/epidemiology
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/therapy
- Ventricular Fibrillation/epidemiology
- Ventricular Fibrillation/etiology
- Ventricular Fibrillation/therapy
- Defibrillators, Implantable/adverse effects
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Cardiomyopathy, Hypertrophic/complications
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/epidemiology
- Adenosine Triphosphate
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Affiliation(s)
- Amitai Segev
- Leviev Heart Center, Sheba Medical Center, Affiliated With Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yishay Wasserstrum
- Leviev Heart Center, Sheba Medical Center, Affiliated With Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Arad
- Leviev Heart Center, Sheba Medical Center, Affiliated With Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jose M Larrañaga-Moreira
- Inherited Cardiovascular Diseases Unit, Cardiology Service, Complexo Hospitalario Universitario A Coruña, Servizo Gaalego de Saúde (SERGAS), Afiiliated With Universidade da Coruña, A Coruña, Spain
| | - Cristina Martinez-Veira
- Inherited Cardiovascular Diseases Unit, Cardiology Service, Complexo Hospitalario Universitario A Coruña, Servizo Gaalego de Saúde (SERGAS), Afiiliated With Universidade da Coruña, A Coruña, Spain
| | - Roberto Barriales-Villa
- Inherited Cardiovascular Diseases Unit, Cardiology Service, Complexo Hospitalario Universitario A Coruña, Servizo Gaalego de Saúde (SERGAS), Afiiliated With Universidade da Coruña, A Coruña, Spain
| | - Avi Sabbag
- Leviev Heart Center, Sheba Medical Center, Affiliated With Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Hansom S, Laksman Z. Implantable Devices in Genetic Heart Disease: Disease-Specific Device Selection and Programming. Card Electrophysiol Clin 2023; 15:249-260. [PMID: 37558296 DOI: 10.1016/j.ccep.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Diagnosis and risk stratification of rare genetic heart diseases remains clinically challenging. In many cases, there are few data and insufficient numbers to support randomized controlled trials. While implantable cardioverter defibrillator (ICD) use is vital to protect higher-risk individuals from life-threatening ventricular arrhythmias, low-risk individuals also require protection from unnecessary ICDs and their associated complications. Once an ICD has been implanted, appropriate device programming is essential to ensure maximal protection while balancing the risks of inappropriate therapy.
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Affiliation(s)
- Simon Hansom
- Division of Cardiology, Arrhythmia Service, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada
| | - Zachary Laksman
- Department of Medicine and the School of Biomedical Engineering, Room 211 - 1033 Davie Street, Vancouver, British Columbia V6E 1M7, Canada.
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 713] [Impact Index Per Article: 356.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Jiménez-Sánchez D, Castro-Urda V, Toquero-Ramos J, Restrepo-Córdoba MA, Sánchez-García M, García-Izquierdo E, Veloza D, Baena-Herrera J, González-López E, Domínguez F, García-Pavía P, Fernández-Lozano I. Benefits of cardiac pacing in ICD recipients with hypertrophic cardiomyopathy. J Interv Card Electrophysiol 2021; 63:165-174. [PMID: 33594661 DOI: 10.1007/s10840-021-00961-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/07/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Implantable cardiac defibrillator (ICD) is the only definitive therapy for prevention of sudden cardiac death in hypertrophic cardiomyopathy (HCM). Conventional transvenous ICDs can provide cardiac pacing unlike new subcutaneous ICD, but the usefulness of cardiac pacing in HCM patients is not well defined. We sought to assess the usefulness of ICD pacing in HCM. METHODS We retrospectively analyzed 93 HCM patients who had undergone ICD implantation at our center. Usefulness of pacing was defined as follows: 1) need of pacing due to bradycardia or AV conduction disturbances, 2) improvement of LV outflow tract obstruction by sequential AV pacing, 3) need for CRT pacing, or 4) successful antitachycardia pacing without a subsequent shock. Independent predictors of useful pacing were investigated by multivariable analysis. RESULTS During a mean follow-up of 91.3 ± 5.5 months, 43 patients (46.2%) reached the composite endpoint. Independent predictors of pacing usefulness were older age (HR 1.36; 95%CI: 1.088-1.709; p=0.007) and NYHA functional class ≥ II (HR 2.15; 95%CI: 1.083-4.301; p=0.029). Twenty-eight (30.1%) patients had appropriate ICD interventions, triggered by a monomorphic ventricular tachycardia (MVT) in 22 of them (78.5%). In 17 individuals with MVT (77%), antitachycardia pacing successfully treated MVT. CONCLUSIONS In our HCM series of patients with ICD, 46% of individuals benefitted from cardiac pacing. MVT were documented in nearly 80% of the patients with ventricular arrhythmias and antitachycardia pacing successfully treated them in 77% of cases.
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Affiliation(s)
- Diego Jiménez-Sánchez
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain.
| | - Víctor Castro-Urda
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain
| | - Jorge Toquero-Ramos
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain
| | - María Alejandra Restrepo-Córdoba
- Heart failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain
| | - Manuel Sánchez-García
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain
| | - Eusebio García-Izquierdo
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain
| | - Darwin Veloza
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain
| | - Jorge Baena-Herrera
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain
| | - Esther González-López
- Heart failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - Fernando Domínguez
- Heart failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - Pablo García-Pavía
- Heart failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain.,CIBERCV, Madrid, Spain.,Universidad Francisco de Vitoria (UFV), Pozuelo de Alarcón, Madrid, Spain
| | - Ignacio Fernández-Lozano
- Electrophysiology Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain.,CIBERCV, Madrid, Spain
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