Influence of advancing age on clinical presentation, treatment efficacy and safety, and long-term outcome of pre-excitation syndromes: a retrospective cohort study of 961 patients included over a 25-year period

Impact of age on catheter ablation of premature ventricular contractions

INTRODUCTION

Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages. The aim of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations.

METHODS

Consecutive patients with symptomatic PVCs undergoing CA between 2015 and 2020 were evaluated. Acute ablation success was defined as the elimination of PVCs at the end of the procedure. Sustained success was defined as an elimination of symptoms, and ≥80% reduction of PVC burden determined by Holter-electrocardiogram during long-term follow. Patients were sub-grouped based on age (<65 vs. ≥65 years).

RESULTS

A total of 114 patients were enrolled (median age 64 years, 71% males) and followed up for a median duration of 228 days. Baseline and procedural data were similar in both age groups. A left-sided origin of PVCs was more frequently observed in the elderly patient group compared to younger patients (83% vs. 67%; p = .04). The median procedure time was significantly shorter in elderly patients (160 vs. 193 min; p = .02). The rates of both acute (86% vs. 92%; p = .32) and sustained success (70% vs. 71%; p = .90) were similar between groups. Complications rates (3.7%) did not differ between the two groups.

CONCLUSION

In a large series of patients with a variety of underlying arrhythmia substrates, similar rates of acute procedural success, complications, and ventricular arrhythmia-free-survival were observed after CA of PVCs. Older age alone should not be a reason to withhold CA of PVCs.

Arrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes

Advances in medical care have led to an increase in the number of octogenarians and even older patients, forming an important and unique patient subgroup. It is clear that advancing age is an independent risk factor for the development of most arrhythmias, causing substantial morbidity and mortality. Patients ≥80 years of age have significant structural and electrical remodeling of cardiac tissue; accrue competing comorbidities; react differently to drug therapy; and may experience falls, frailty, and cognitive impairment, presenting significant therapeutic challenges. Unfortunately, very old patients are under-represented in clinical trials, leading to critical gaps in evidence to guide effective and safe treatment of arrhythmias. In this state-of-the-art review, we examine the pathophysiology of aging and arrhythmias and then present the available evidence on age-specific management of the most common arrhythmias, including drugs, catheter ablation, and cardiac implantable electronic devices.

Catheter ablation in elderly patients: a review of current studies and pending questions

PURPOSE OF REVIEW

Catheter ablations are established treatment options for cardiac arrhythmias. Despite the fact that they are increasingly performed in elderly patients, publications focusing on procedural safety and success concerning this patient subgroup are sparse. The purpose of this review is to inform about current and upcoming studies regarding catheter ablations in the elderly.

RECENT FINDINGS

The overall pattern of available studies is indistinct because of varying age limits and scant patient populations. Most studies do not identify advanced patient age as a promoting factor for peri-procedural complications and recurrence rates. There are a few upcoming publications with regards to catheter ablations in the elderly, some of which might produce new insight.

SUMMARY

The results at hand might implicate, that in most cases individual patient health could be decisive instead of mere patient age to promise well-tolerated and effective catheter ablation in aged patients. Nevertheless, further studies with larger patient populations are needed to clarify the role of catheter ablation in aged patients.

Unresolved questions associated with the management of ventricular preexcitation syndrome

BACKGROUND

Many recent recommendations concern the management of preexcitation syndrome. In clinical practice, they are sometimes difficult to use. The purpose of the authors was to discuss the main problems associated with this management. Three problems are encountered: (1) the reality of the absence of symptoms or the interpretation of atypical symptoms, (2) the electrocardiographic diagnosis of preexcitation syndrome that can be missed, and (3) the exact electrophysiological protocol and its interpretation used for the evaluation of the prognosis. Because of significant progress largely related to the development of curative treatment, it seems easy to propose ablation in many patients despite the related risks of invasive studies and to minimize the invasive risk by only performing ablation for patients with at-risk pathways. However, there is a low risk of spontaneous events in truly asymptomatic patients and the indication of accessory pathway ablation should be discussed case by case.

Influence of advancing age on clinical presentation, treatment efficacy and safety, and long-term outcome of inducible paroxysmal supraventricular tachycardia without pre-excitation syndromes: A cohort study of 1960 patients included over 25 years

AIM

To investigate the influence of increasing age on clinical presentation, treatment and long-term outcome in patients with inducible paroxysmal supraventricular tachycardia (SVT) without pre-excitation syndromes.

METHODS

Clinical and electrophysiological study (EPS) data, as well as long-term clinical outcome (mean follow-up 2.4±4.0 years) were collected in patients referred for regular tachycardia with inducible SVT during EPS without pre-excitation.

RESULTS

Among 1960 referred patients, 301 patients (15.4%) were aged ≥70 (70-97). In this subset, anticoagulants were prescribed in 49 patients following an erroneous diagnosis of atrial tachycardia and 14 were previously erroneously diagnosed with ventricular tachycardia because of wide QRS. Ablation was performed more frequently in patients ≥70 despite more frequent failure and complications. During follow-up, higher risks of AF, stroke, pacemaker implantation and death were observed in patients ≥70 whereas SVT recurrences were similar in both age groups. In multivariable analysis, age ≥70 was independently associated with higher risks of SVT-related adverse events prior to ablation (OR = 1.93, 1.41-2.62, p<0.001), conduction disturbances (OR = 11.27, 5.89-21.50, p<0.001), history of AF (OR = 2.18, 1.22-3.90, p = 0.009) and erroneous diagnosis at baseline (OR = 9.14, 5.93-14.09, p<0.001) as well as high rates of procedural complications (OR = 2.13, 1.19-3.81, p = 0.01) and ablation failure (OR = 1.68, 1.08-2.62, p = 0.02). In contrast, age ≥70 was not significantly associated with a higher risk of AF in multivariable analysis.

CONCLUSIONS

A sizeable proportion of patients with inducible SVT without pre-excitation syndromes are elderly. These patients exhibit higher risks of erroneous tachycardia diagnosis prior to EPS as well as failure and/or complication of ablation, but similar risk of SVT recurrence. These results support performing transesophageal EPS in most patients and intracardiac EPS in selected patients. EPS may furthermore prove useful in elderly patients with regular tachycardia, mainly by avoiding treatment based on an erroneous diagnosis.

Electrocardiographic Preexcitation and Risk of Cardiovascular Morbidity and Mortality: Results From the Copenhagen ECG Study

BACKGROUND

The majority of available data on the clinical course of patients with ventricular preexcitation in the ECG originates from tertiary centers. We aimed to investigate long-term outcomes in individuals from a primary care population with electrocardiographic preexcitation.

METHODS AND RESULTS

Digital ECGs from 328 638 primary care patients were collected during 2001 to 2011. We identified 310 individuals with preexcitation (age range, 8-85 years). Data on medication, comorbidity, and outcomes were collected from Danish nationwide registries. The median follow-up time was 7.4 years (quartiles, 4.6-10.3 years). Compared with the remainder of the population, patients with preexcitation had higher adjusted hazards of atrial fibrillation (hazard ratio [HR], 3.12; 95% confidence interval [CI], 2.07-4.70) and heart failure (HR, 2.11; 95% CI, 1.27-3.50). Subgroup analysis on accessory pathway location revealed a higher adjusted hazard of heart failure for a right anteroseptal accessory pathway (HR, 5.88; 95% CI, 2.63-13.1). There was no evidence of a higher hazard of death among individuals with preexcitation when looking across all age groups (HR, 1.07; 95% CI, 0.68-1.68). However, a statistically significant (P=0.01) interaction analysis (<65 versus ≥65 years) indicated a higher hazard of death for patients with preexcitation ≥65 years (HR, 1.85; 95% CI, 1.07-3.18).

CONCLUSIONS

In this large ECG study, individuals with preexcitation had higher hazards of atrial fibrillation and heart failure. The higher hazard of heart failure seemed to be driven by a right anteroseptal accessory pathway. Among elderly people, we found a statistically significant association between preexcitation and a higher hazard of death.