Outcomes of catheter ablation in high-risk patients with Brugada syndrome refusing an implantable cardioverter defibrillator implantation

Long-term of epicardial radiofrequency ablation and benefit for recurrent ventricular arrhythmia in Brugada syndrome: A systematic review and meta-analysis

Background

Brugada syndrome (BrS) is a rare cardiac channelopathy linked to an increased risk of ventricular arrhythmias (VA) and sudden cardiac death. Radiofrequency ablation (RFA), particularly epicardial ablation, is recommended for BrS patients with recurrent VA unresponsive to conventional treatments like implantable cardioverter-defibrillators (ICD) and quinidine. This study aims to evaluate the long-term efficacy of epicardial RFA in preventing VA recurrence in BrS.

Methods

A systematic search of PubMed, ScienceDirect, Cochrane Library, and ProQuest databases was conducted following PRISMA 2020 guidelines. Studies on RFA for VA in BrS were included. Primary outcomes were VA recurrence and all-cause mortality. Statistical analysis was performed using Review Manager 5.4.

Results

Epicardial, endocardial, and combined ablation strategies effectively reduced VA recurrence, decreased ICD shocks, and improved clinical outcomes in BrS. Epicardial ablation RFA near coronary arteries showed a notable reduction in VA recurrence, while endocardial ablation remained a viable alternative. Meta-analysis revealed a significant reduction in VA recurrence (RR 0.17; 95% CI 0.07-0.43; p < .0001) and ICD shocks (RR 0.13; 95% CI 0.04-0.44; p = .001). Subgroup analysis suggested greater VA reduction with epicardial ablation, though without statistical significance.

Conclusion

Epicardial RFA is associated with a significant reduction in recurrent VAs (83%) and ICD shock rates (87%) in patients with BrS. The procedure demonstrates a favorable long-term safety profile, with no mortality reported in the included studies.

Epicardial ablation in high-risk Brugada syndrome to prevent ventricular fibrillation: results from a randomized clinical trial

AIMS

Epicardial ablation for Brugada syndrome (BrS) has shown promise in reducing ventricular fibrillation (VF), but its role remains controversial due to the lack of randomized trials. This study evaluates the efficacy of catheter ablation in high-risk BrS patients.

METHODS AND RESULTS

This prospective, single-centre, randomized (2:1) study enrolled BrS patients with cardiac arrest (CA) or appropriate ICD therapies. All patients had an ICD and were randomized to undergo epicardial ablation (ablation group) or no ablation (control group). Enrolment began in September 2017 and prematurely terminated in February 2024. The primary endpoint was freedom from VF recurrences. Secondary endpoints included procedure safety, ICD-related complications, and quality-of-life assessment. Forty patients (83% male, mean age 43.7 ± 12.1) were randomized: 26 in the ablation group and 14 in the control group. Thirty-six patients received appropriate ICD therapies before enrolment: 24 (92%) in the ablation group and 12 (86%) in the control group. One patient in the ablation group experienced a post-procedural pericardial effusion requiring pericardiocentesis. Thirteen patients (33%) had major ICD-related complications. After a mean follow-up of 4.0 ± 1.7 years, freedom from VF recurrence was 96% (25/26) in the ablation group and 50% (7/14) in the control group (P < 0.001). No unexplained or arrhythmic deaths occurred during follow-up.

CONCLUSION

Epicardial catheter ablation was associated with a reduction in VF recurrence compared with ICD therapy alone. These findings support the use of epicardial ablation in high-risk BrS patients.

CLINICALTRIALS.GOV

ID NCT03294278.

Epicardial ventricular arrhythmia ablation: a clinical consensus statement of the European Heart Rhythm Association of the European Society of Cardiology and the Heart Rhythm Society, the Asian Pacific Heart Rhythm Society, the Latin American Heart Rhythm Society, and the Canadian Heart Rhythm Society

Epicardial access during electrophysiology procedures offers valuable insights and therapeutic options for managing ventricular arrhythmias (VAs). The current clinical consensus statement on epicardial VA ablation aims to provide clinicians with a comprehensive understanding of this complex clinical scenario. It offers structured advice and a systematic approach to patient management. Specific sections are devoted to anatomical considerations, criteria for epicardial access and mapping evaluation, methods of epicardial access, management of complications, training, and institutional requirements for epicardial VA ablation. This consensus is a joint effort of collaborating cardiac electrophysiology societies, including the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, the Latin American Heart Rhythm Society, and the Canadian Heart Rhythm Society.

Catheter ablation as an adjunctive therapy to ICD implantation in Brugada Syndrome

BACKGROUND

Brugada Syndrome (BrS) is a life-threatening cardiac arrhythmia disorder associated with an increased risk of ventricular arrhythmias (VAs) and sudden cardiac death. Current management primarily relies on implantable cardioverter-defibrillators (ICDs), but patients may experience ICD shocks. Catheter ablation (CA) has emerged as a potential intervention to target the arrhythmogenic substrate. This systematic review aims to evaluate the safety and efficacy of CA in BrS patients.

METHODS AND RESULTS

Studies with BrS patients undergoing CA for VAs were included. Fourteen studies that involved a total population of 709 BrS patients, with CA performed in 528 of them, were included. CA resulted in the non-inducibility of VAs in 91% (95% CI: 83-99, I2 = 76%) and resolution of type 1 ECG Brugada pattern in 88% (95% CI: 81-96.2, I2 = 91%) of the patients. After a mean follow-up of 30.7 months, 87% (95% CI: 80-94, I2 = 82%) of patients remained free from VAs. The incidence of VAs during follow-up was significantly lower in the ablation cohort in comparison to the group receiving only ICD therapy (OR = 0.03, 95% CI: 0.01-0.12, I2 = 0%).

CONCLUSION

CA shows potential as a therapeutic approach to reduce VAs and improve outcomes in BrS patients. While further research with a long follow-up period is required to confirm these findings, it represents a valuable tool as an add-on intervention to ICD implantation in BrS patients with a high burden of VAs.

High-risk Brugada syndrome: factors associated with arrhythmia recurrence and benefits of epicardial ablation in addition to implantable cardioverter defibrillator implantation

AIMS

This study aims to evaluate the prognostic impact of the arrhythmogenic substrate size in symptomatic Brugada syndrome (BrS) as well as to validate the long-term safety and effectiveness of epicardial radiofrequency ablation (RFA) compared with no-RFA group.

METHODS AND RESULTS

In this prospective investigational long-term registry study, 257 selected symptomatic BrS patients with implantable cardioverter defibrillator (ICD) implantation were included. Among them, 206 patients underwent epicardial RFA and were monitored for over 5 years post-ablation (RFA group), while 51 patients received only ICD implantation declining RFA. Primary endpoints included risk factors for ventricular fibrillation (VF) events pre-ablation and freedom from VF events post-ablation. In the RFA group, BrS substrates were identified in the epicardial surface of the right ventricle. During the pre-RFA follow-up period (median 27 months), VF episodes and VF storms were experienced by 53 patients. Independent risk factors included substrate size [hazard ratio (HR), 1.13; 95% confidence interval (CI), 1.08-1.18; P < 0.001], aborted cardiac arrest (HR, 2.98; 95% CI, 1.68-5.28; P < 0.001), and SCN5A variants (HR, 2.22; 95% CI, 1.15-4.27; P = 0.017). In the post-RFA follow-up (median 40 months), the RFA group demonstrated superior outcomes compared with no-RFA (P < 0.001) without major procedure-related complications.

CONCLUSION

Our study underscores the role of BrS substrate extent as a crucial prognostic factor for recurrent VF and validates the safety and efficacy of RFA when compared with a no-RFA group. Our findings highlight the importance of ajmaline in guiding epicardial mapping/ablation in symptomatic BrS patients, laying the groundwork for further exploration of non-invasive methods to guide informed clinical decision-making.