Safety of ventricular tachycardia ablation in clinical practice: findings from 9699 hospital discharge records

Impact of Hospital VT Ablation Volume on Post-Procedural Complications: Argument for Selective Referral to High-Volume Centers

BACKGROUND

Existing studies have shown a relationship between hospital case volume and outcomes of various cardiovascular procedures. The impact of hospital procedure volume on complications of catheter ablation of ventricular tachycardia (VT) and the potential benefit of selective referral to high-volume centers have not been previously evaluated.

OBJECTIVES

This study sought to assess the associations between hospital procedure volume of VT catheter ablation and postprocedural morbidity and mortality.

METHODS

The NIS (National Inpatient Sample) database was queried for hospital admissions for VT ablation in the United States during the year 2019. Hospitals were divided into tertiles of VT ablation volume (high-volume hospitals [HVH] ≥50 ablations per year, medium-volume hospitals performed 16-49 ablations, and low-volume hospitals [LVH] ≤ 15 ablations). Data on adverse events including in-hospital mortality and postprocedural complications were collected.

RESULTS

Patients in HVH were more likely to have comorbidities including heart failure (74.3% vs 64.7%; P = 0.02) and kidney disease (25.3% vs 21.7%; P = 0.044) than LVH. After controlling for baseline confounders and with LVH as reference, HVH had lower in-hospital mortality (adjusted OR [aOR] = 0.80; 95% CI: 0.71-0.91; P = 0.04), cardiac tamponade (aOR = 0.58; 95% CI: 0.32-0.78; P = 0.01), and need for blood transfusion (aOR = 0.41; 95% CI: 0.21-0.68; P = 0.008). It can be estimated that for every 17 patients shifted from LVH to HVH, 1 death, cardiac tamponade, or major bleeding event could be prevented.

CONCLUSIONS

Patients undergoing VT ablation at HVH were sicker on average, yet had lower in-hospital mortality and procedure-related morbidity compared to LVH. Selective VT patient referral to HVH has the potential to substantially reduce in-hospital complications following VT ablation nationally.

Mortality and readmissions after ventricular tachycardia ablation: An analysis of inpatient and outpatient state databases

BACKGROUND

Catheter ablation is an effective therapy for ventricular tachycardia (VT) and is increasing in use. Assessment of contemporary real-world outcomes of VT ablation requires data inclusive of both inpatient and outpatient encounters.

OBJECTIVE

We aimed to assess factors associated with 1-year in-hospital mortality, all-cause readmission, and recurrent readmission for VT after VT ablation along with the associated costs of care.

METHODS

Inpatient and outpatient VT ablations were captured in the Healthcare Cost and Utilization Project data in Florida, Maryland, and New York from 2016 to 2020 with 1-year follow-up through 2021. Cox proportional hazards regression was used to identify risk factors associated with 1-year in-hospital mortality, all-cause readmission, and recurrent VT readmission. Costs of inpatient cases and readmission were captured.

RESULTS

Of 3899 patients undergoing VT ablation, 2% died during the initial episode of care. The 1-year in-hospital mortality rate, all-cause readmission rate, and recurrent VT readmission rate were 6.8%, 43.4%, and 16.9%, respectively, and were broadly stable during the study period. Coronary artery disease, chronic kidney disease, and heart failure were independently associated with an increased risk of in-hospital mortality and all-cause readmission within 1 year (P < .05). Recurrent VT was the most common cause of readmission. All-cause readmissions increased costs by 55%.

CONCLUSION

Mortality, long-term readmission, and recurrent VT remain high after VT ablation and include measurably important costs. Strategies to improve freedom from recurrent VT while managing comorbid conditions may serve as targets for improving the efficacy and cost-effectiveness of an important procedure applied to a vulnerable population.

Safety of immediate catheter ablation of ventricular arrhythmias in patients admitted via the emergency department

BACKGROUND

In patients with ventricular arrhythmias (VA) admitted via the emergency department (ED), immediate catheter ablation (CA-VA) might be indicated to stabilize patients. However, the unstable condition of these patients may increase periprocedural risk. This study evaluated the periprocedural safety of immediate CA-VA in patients admitted via the ED.

METHODS AND RESULTS

In total, 223 ED patients who underwent immediate CA-VA from 01/2017 to 12/2022 (mean age 66 ± 13 years, 19% female, 55% heart failure, 59% coronary artery disease) were analyzed in terms of in-hospital outcomes (periprocedural death, pericardial tamponade, thromboembolic events, major bleedings). To address differences to elective patients, ED patients were compared with 784 elective CA-VA patients (mean age 59 ± 15 years, 34% female, 20% heart failure, 33% coronary artery disease, all p < 0.001): ED patients experienced higher rates of periprocedural complications (6.3% vs. 2.0%, p = 0.002) driven by thromboembolic events (2.2% vs. 0.4%, p = 0.02). Life-threatening complications were not different between groups (cardiac tamponade: 2.2% vs. 1.4%, p = 0.56; stroke: 0.9% vs. 0.4%, p = 0.67). Seven ED patients (3.1%) died unrelated to the procedure during hospitalization vs. none in the elective CA-VA group. Emergency admission (OR 3.07, 95% CI 1.48-6.38), age (OR 2.12, 95% CI 1.22-3.70), and heart failure (OR 1.99, 95% CI 0.96-4.15) were independently associated with periprocedural complications and overall death during hospitalization.

CONCLUSION

Patients with VA admitted via the ED were older, sicker, and more often presented with ventricular tachycardia than elective CA-VA patients. Immediate CA-VA was associated with higher rates of periprocedural complications, driven by thromboembolic events; however, no procedure-related death occurred.

[Epicardial ablation of ventricular tachycardia with cardiac surgery only : Pro/Contra]

During the ablation of ventricular arrhythmias (VA) complications can occur, albeit rather rarely, and their occurrence depends on various factors. On the one hand the patient's condition and comorbidities play a role, on the other hand the access site and the procedure itself can lead to complications which have to be addressed adequately. This article will discuss whether complex ablations with epicardial access should only be performed at centres with the appropriate expertise and a cardiac surgery department.

In-Hospital Outcomes of Ventricular Tachycardia Catheter Ablation in the Presence of Intra-Cardiac Thrombus

BACKGROUND

Ventricular tachycardia (VT) catheter ablation in the presence of intracardiac thrombi was evaluated in very few studies.

OBJECTIVES

To investigate in-hospital outcomes of VT ablation in the presence of an intracardiac thrombus, in a large inpatient US registry.

METHODS

Using the National Inpatient Sample (NIS) database, patients who underwent non-elective VT catheter ablations in the United States between 2016 and 2019 were identified using ICD-10 codes. Sociodemographic, clinical data, in-hospital procedures, and outcomes as well as in-hospital mortality were collected. In-hospital outcomes were compared using propensity score (PS) matching analysis with a 1:3 ratio between patients with and without intracardiac thrombus.

RESULTS

A weighted total of 15,725 admissions for non-elective VT ablation were included in the study, of which 190 (1.2%) had a discharge diagnosis of intracardiac thrombus. Patients with intracardiac thrombus had a higher comorbidity burden and were more likely to have ischemic cardiomyopathy and a diagnosis of cardiac aneurysm. In PS analysis, the presence of intracardiac thrombus was significantly associated with higher rates of any in-hospital complications (42.1% vs. 19.3%, p < 0.009), driven by higher periprocedural cerebrovascular accident and vascular injury events. In-hospital mortality rates were not significantly different between the groups.

CONCLUSIONS

In patients undergoing non-elective VT ablation, intracardiac thrombus was associated with higher rates of in-hospital complications, but not higher in-hospital mortality. These findings suggest that intracardiac thrombus should not contraindicate VT ablation when deemed necessary, while efforts should be made to decrease potential complications.

Pulsed-Field Ablation in Management of Ventricular Tachycardia: A Systematic Review of Case Reports and Clinical Outcomes

BACKGROUND

Pulsed-field ablation (PFA) is a cutting-edge technique that employs non-thermal energy to cause cell death by inducing irreversible electroporation of cell membranes. This systematic review evaluates the PFA effectiveness as a potential alternative to radiofrequency and cryo-ablation for treating ventricular tachycardia.

METHODS

PubMed, Embase, Scopus, and Web of Science were systematically searched using keywords related to ventricular tachycardia and pulsed-field ablation. Eligible Studies evaluating this therapeutic approach for ventricular tachycardia were included in the final analysis.

RESULTS

We included six studies (five case reports and one case series) in our systematic review. Eight (88.8%) of procedures were successful with 100% long-term efficacy. No procedural complications or ventricular tachycardia (VT) recurrence were observed in the cases.

CONCLUSION

The absence of complications, high effectiveness, and long-term success rate make PFAs a good VT treatment option. However, PFA safety and efficacy studies for VT treatment are scarce. Thus, larger investigations on this topic are urgently needed.

Management of patients with electrical storm: an educational review

Electrical storm (ES) is a medical emergency that is defined as ≥ 3 separate ventricular tachycardia (VT) episodes causing ICD therapy within 24 h. Patients with ES have high risk for hospitalization, heart failure (HF) decompensation, in-hospital death. Furthermore, it is associated with significant anxiety and distress for the patients. Frequent triggers of ES are myocardial ischaemia, acute decompensation of HF, metabolic and electrolyte disorders, drug side-effects, increased sympathetic tone. Acute management of ES requires sedation, antiarrhythmic drugs and correction of the precipitating factors; although, in severe refractory cases, intubation, mechanical ventilation, and circulatory support might be necessary. Radiofrequency catheter ablation is superior than antiarrhythmic drugs to suppress the ES and is also frequently required to terminate the ES, as well as to achieve acute and long-term freedom of VT. Optimization of the ICD programming is crucial to reduce the burden of further appropriate and inappropriate shocks. Use of appropriate discrimination criteria and algorithms, ATPs and extending the detection times are important measures to reduce the burden of ES. In patients with end-stage HF, ES can be a sign of failing heart and can be refractory of treatment. In such cases, deactivation of the ICD therapy should be considered and discussed with patients and their care givers.

Complications of catheter ablation for ventricular tachycardia

With the increasing literature demonstrating benefits of catheter ablation for ventricular tachycardia (VT), the number of patients undergoing VT ablation has increased dramatically. As VT ablation is being performed more routinely, operators must be aware of potential complications of VT ablation. This review delves deeper into the practice of VT ablation with a focus on periprocedural complications.

Near zero vascular complications using echo-guided puncture during catheter ablation of arrhythmias: A retrospective study and literature review

BACKGROUND

Catheter ablation (CA) is routinely used for the treatment of arrhythmias. Vascular complications are the most common complications during these procedures. Previous data reported that ultrasound (US)-guided puncture is a useful method to avoid vascular complications. We reported our experience using US-guided puncture in patients undergoing CA for arrhythmias.

METHODS

A total of 273 patients (mean age 57 ± 17 years; 58% male) were referred to our center for CA of arrhythmias from January 2016 to December 2019. All procedures were performed by expert operators, and US-guided vascular access was performed on all patients. Doppler sonography was performed the day after the procedure on all patients.

RESULTS

Eighty-four patients (31%) underwent atrioventricular nodal reentrant tachycardia ablation, 49 patients (18%) atrioventricular reentrant tachycardia ablation, 14 patients (5%) atrial tachycardia ablation, 25 patients (9%) atrial flutter ablation, 63 patients (23%) atrial fibrillation ablation, and 38 patients (14%) ventricular tachycardia ablation. Vascular pseudo-aneurysms and arteriovenous fistula were defined as major complications; furthermore, venous thrombosis and inguinal hematomas were as defined minor complications. The percentage of major vascular complications was 0.3% (1 arteriovenous fistula) and the percentage of minor vascular complications was 0.3% (1 venous thrombosis).

DISCUSSION

Ultrasound-guided vascular puncture in patients undergoing CA is useful to improve procedural success and reduce complications.

Complications and mortality after catheter ablation of ventricular arrhythmias: risk in VT ablation (RIVA) score

AIMS

Catheter ablation of ventricular arrhythmias (VA) has proven to be an effective therapeutic option for secondary arrhythmia prophylaxis. We sought to assess the procedural efficacy, safety and in-hospital mortality of a large patient cohort with and without structural heart disease undergoing VA ablation.

METHODS

A total of 1417 patients (804 patients with structural heart disease) undergoing 1792 endo- and epicardial procedures were analyzed. Multivariable risk factor analysis for occurrence of major complications and intrahospital mortality was obtained and a score to allow preprocedural risk assessment for patients undergoing VA ablation procedures was established.

RESULTS

Major complication occurred in 4.4% of all procedures and significantly more often in patients with structural heart disease than in structurally normal hearts (6.0 vs. 1.8%). The frequency of these periprocedural complications was significantly different between procedures with sole right ventricular and a combination of RV and LV access (0.5 vs. 3.1%). The most common complication was cardiac tamponade in 46 cases (3.0%). Intrahospital death was observed in 32 patients (1.8%). Logistic regression model revealed presence of ischemic heart disease, epicardial ablation, presence of oral anticoagulation or dual antiplatelet therapy as independent risk factors for the occurrence of complications or intrahospital death, while a history of previous heart surgery was an independent predictor with a decreased risk. Based on this analysis a risk score incorporating 5 standard variables was established to predict the occurrence of complications and intrahospital mortality.

CONCLUSIONS

Safety of VA catheter ablation mainly relies on patient baseline characteristics and the type of access into the ventricles or epicardial space.

Management of ventricular tachycardia in patients with ischaemic cardiomyopathy: contemporary armamentarium

Worldwide, ∼4 million people die from sudden cardiac death every year caused in more than half of the cases by ischaemic cardiomyopathy (ICM). Prevention of sudden cardiac death after myocardial infarction by implantation of a cardioverter-defibrillator (ICD) is the most common, even though not curative, therapy to date. Optimized ICD programming should be strived for in order to decrease the incidence of ICD interventions. Catheter ablation reduces the recurrence of ventricular tachycardias (VTs) and is an important adjunct to sole ICD-based treatment or pharmacological antiarrhythmic therapy in patients with ICM, as conclusively demonstrated by seven randomized controlled trials (RCTs) in the last two decades. However, none of the conducted trials was powered to reveal a survival benefit for ablated patients as compared to controls. Whereas thorough consideration of an early approach is necessary following two recent RCTs (PAUSE-SCD, BERLIN VT), catheter ablation is particularly recommended in patients with recurrent VT after ICD therapy. In this context, novel, pathophysiologically driven ablation strategies referring to deep morphological and functional substrate phenotyping based on high-resolution mapping and three-dimensional visualization of scars appear promising. Emerging concepts like sympathetic cardiac denervation as well as radioablation might expand the therapeutical armamentarium especially in patients with therapy-refractory VT. Randomized controlled trials are warranted and on the way to investigate how these translate into improved patient outcome. This review summarizes therapeutic strategies currently available for the prevention of VT recurrences, the optimal timing of applicability, and highlights future perspectives after a PAUSE in BERLIN.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Catheter ablation of ventricular tachycardia in patients with prior cardiac surgery: An analysis from the International VT Ablation Center Collaborative Group

INTRODUCTION

Patients with prior cardiac surgery may represent a subgroup of patients with ventricular tachycardia (VT) that may be more difficult to control with catheter ablation.

METHODS

We evaluated 1901 patients with ischemic and nonischemic cardiomyopathy who underwent VT ablation at 12 centers. Clinical characteristics and VT radiofrequency ablation procedural outcomes were assessed and compared between those with and without prior cardiac surgery. Kaplan-Meier analysis was used to estimate freedom from recurrent VT and survival.

RESULTS

There were 578 subjects (30.4%) with prior cardiac surgery identified in the cohort. Those with prior cardiac surgery were older (66.4 ± 11.0 years vs. 60.5 ± 13.9 years, p < .01), with lower left ventricular ejection fraction (30.2 ± 11.5% vs. 34.8 ± 13.6%, p < .01) and more ischemic heart disease (82.5% vs. 39.3%, p < .01) but less likely to undergo epicardial mapping or ablation (9.0% vs. 38.1%, p<.01) compared to those without prior surgery. When epicardial mapping was performed, a significantly greater proportion required surgical intervention for access (19/52 [36.5%] vs. 14/504 [2.8%]; p < .01). Procedural complications, including epicardial access-related complications, were lower (5.7% vs. 7.0%, p < .01) in patients with versus without prior cardiac surgery. VT-free survival (75.1% vs. 74.1%, p = .805) and survival (86.5% vs. 87.9%, p = .397) were not different between those with and without prior heart surgery, regardless of etiology of cardiomyopathy. VT recurrence was associated with increased mortality in patients with and without prior cardiac surgery.

CONCLUSION

Despite different clinical characteristics and fewer epicardial procedures, the safety and efficacy of VT ablation in patients with prior cardiac surgery is similar to others in this cohort. The incremental yield of epicardial mapping in predominant ischemic cardiomyopathy population prior heart surgery may be low but appears safe in experienced centers.

Arrhythmic Risk Profile and Outcomes of Patients Undergoing Cardiac Sympathetic Denervation for Recurrent Monomorphic Ventricular Tachycardia After Ablation

Background

Cardiac sympathetic denervation (CSD) has been used as a bailout strategy for refractory ventricular tachycardia (VT). Risk of VT recurrence in patients with scar‐related monomorphic VT referred for CSD and the extent to which CSD can modify this risk is unknown. We aimed to quantify arrhythmia recurrence risk and impact of CSD in this population.

Methods and Results

Adjusted competing risk time to event models were developed to adjust for risk of VT recurrence and sustained VT/implantable cardioverter–defibrillator shocks after VT ablation based on patient comorbidities at the time of VT ablation. Adjusted VT and implantable cardioverter–defibrillator shock recurrence rates were estimated for the subgroup who subsequently required CSD after ablation. The expected adjusted recurrence rates were then compared with the observed rates after CSD. Data from 381 patients with scar‐mediated monomorphic VT who underwent VT ablation were analyzed, excluding patients with polymorphic VT. Sixty eight patients underwent CSD for recurrent VT. CSD reduced the expected adjusted VT recurrence rate by 36% (expected rate of 5.61 versus observed rate of 3.58 per 100 person‐months, P=0.01) and the sustained VT/implantable cardioverter–defibrillator shock rates by 34% (expected rate of 4.34 versus observed 2.85 per 100 person‐months, P=0.03). The median number of sustained VT/implantable cardioverter–defibrillator shocks in the year before versus the year after CSD was reduced by 90% (10 versus 1, P<0.0001).

Conclusions

Patients referred for CSD for refractory scar‐mediated monomorphic VT are at a higher risk of VT recurrence after ablation as compared with those not requiring CSD, mostly because of their cardiac comorbidities. CSD significantly reduced both the expected risk of recurrences and VT burden.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Patient characteristics, procedure details including catheter devices, and complications of catheter ablation for ventricular tachycardia: a nationwide observational study

Background

Nationwide data are insufficient with respect to the characteristics of patients undergoing ventricular tachycardia (VT) ablation, complications of VT ablation, and procedure details including catheter devices used during VT ablation. The present study was performed to describe the patient characteristics, procedure details including catheter devices, and in‐hospital complications of catheter ablation for VT using a national inpatient database.

Methods

We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify patients who underwent VT ablation from July 2010 to March 2017. We examined patients’ age, gender, baseline diseases, comorbid conditions, admission status, catheter devices and drugs used, and in‐hospital complications of VT ablation.

Results

We identified 10 641 patients (median age, 61 years) who underwent VT ablation. The most frequently observed background heart disease among patients with structural heart disease was ischemic cardiomyopathy. An irrigated ablation catheter was used in 73% of patients, a force‐sensing ablation catheter was used in 22%, and intracardiac echocardiography was used in 25%. The frequency of using these procedures continuously increased over time. Overall, the prevalence of in‐hospital complications was 3.5% (cardiac tamponade, 0.8%; stroke, 0.6%; critical bleeding, 1.9%; mechanical circulatory support, 0.9%; and in‐hospital death, 0.8%).

Conclusions

The results of this study show the clinical features of VT ablation in a real‐world clinical setting. The use of irrigated catheters, force‐sensing catheters, and intracardiac echocardiography increased over time. The prevalence of in‐hospital complications was 3.5%.

Intracardiac echocardiography use and outcomes after catheter ablation of ventricular tachycardia

Aim: To compare outcomes among patients with implantable cardioverter defibrillator/cardiac resynchronization therapy-defibrillator undergoing outpatient ventricular tachycardia (VT) catheter ablation using intracardiac echocardiography (ICE) versus no ICE. Patients & methods: Patients were classified into ICE (n = 1143)/non-ICE (n = 1677) groups based on ICE procedure codes. Patients in each group were propensity matched on study covariates. Survival analyses were used to assess outcomes. To examine residual confounding, falsification outcomes were evaluated. Results: ICE patients had a 24% lower risk of all-cause readmissions, 24% lower risk of cardiovascular-related and 20% lower risk of VT-related readmissions compared with non-ICE patients. Falsification analyses for ICE use association were nonsignificant. Conclusion: Patients with implantable cardioverter defibrillator/cardiac resynchronization therapy-defibrillator undergoing VT ablation with ICE use had significantly lower likelihood of VT-related readmission.

Cardiac Magnetic Resonance-Guided Ventricular Tachycardia Substrate Ablation

OBJECTIVES

This study assessed the feasibility and potential benefit of performing ventricular tachycardia (VT) substrate ablation procedures guided by cardiac magnetic resonance (CMR)-derived pixel signal intensity (PSI) maps.

BACKGROUND

CMR-aided VT ablation using PSI maps from late gadolinium enhancement-CMR (LGE-CMR), together with electroanatomical map (EAM) information, has been shown to improve outcomes of VT substrate ablation.

METHODS

Eighty-four patients with scar-dependent monomorphic VT who underwent substrate ablation were included in the study. In the last 28 (33%) consecutive patients, the procedure was guided by CMR. Procedural data, as well as acute and follow-up outcomes, were compared between patients who underwent guided CMR and 2 control groups: 1) patients who had PSI maps were available but the EAM was acquired and used to select the ablation targets (CMR aided); and 2) patients with no CMR-derived PSI maps available (no CMR).

RESULTS

Mean procedure duration was lower in CMR-guided substrate ablation compared with CMR-aided and no CMR (107 ± 59 min vs. 203 ± 68 min and 227 ± 52 min; p < 0.001 for both comparisons). CMR-guided ablation required less fluoroscopy time than CMR-aided ablation and no CMR (10 ± 4 min vs. 23 ± 11 min and 20 ± 9 min, respectively; p < 0.001 for both comparisons) and less radiofrequency time (15 ± 8 min vs. 20 ± 15 min and 26 ± 10 min; p = 0.16 and p < 0.001, respectively). After substrate ablation, VT inducibility was lower in CMR-guided ablation compared with CMR-aided ablation and no CMR (18% vs. 32% and 46%; p = 0.35 and p = 0.04, respectively), without significant differences in complications. After 12 months, VT recurrence was lower in those who underwent CMR-guided ablation compared with no CMR (log-rank: 0.019), with no differences with CMR-aided ablation.

CONCLUSIONS

CMR-guided VT ablation is feasible and safe, significantly reduces the procedural, fluoroscopy, and radiofrequency times, and is associated with a higher noninducibility rate and lower VT recurrence after substrate ablation.

Catheter ablation of ventricular arrhythmias and in-hospital mortality: insights from the German-wide Helios hospital network of 5052 cases

AIMS

Catheter ablation (CA) of ventricular arrhythmias is one of the most challenging electrophysiological interventions with an increasing use over the last years. Several benefits must be weighed against the risk of potentially life-threatening complications which necessitates a steady reevaluation of safety endpoints. Therefore, the aims of this study were (i) to investigate overall in-hospital mortality in patients undergoing such procedures and (ii) to identify variables associated with in-hospital mortality in a German-wide hospital network.

METHODS AND RESULTS

Between January 2010 and September 2018, administrative data provided by 85 Helios hospitals were screened for patients with main or secondary discharge diagnosis of ventricular tachycardia (VT) or premature ventricular contractions (PVCs) in combination with an arrhythmia-related CA using ICD- and OPS codes. In 5052 cases (mean age 60.9 ± 14.3 years, 30.1% female) of 30 different hospitals, in-hospital mortality was 1.27% with a higher mortality in patients ablated for VT (1.99%, n = 2, 955) compared to PVC (0.24%, n = 2, 097, P < 0.01). Mortality rates were 2.06% in patients with ischaemic heart disease (IHD, n = 2, 137), 1.47% in patients with non-ischaemic structural heart disease (NIHD, n = 1, 224), and 0.12% in patients without structural heart disease (NSHD, n = 1, 691). Considering different types of hospital admission, mortality rates were 0.35% after elective (n = 2, 825), 1.60% after emergency admission/hospital transfer <24 h (n = 1, 314) and 3.72% following delayed hospital transfer >24 h after initial admission (n = 861, P < 0.01 vs. elective admission and emergency admission/hospital transfer <24 h). In multivariable analysis, a delayed hospital transfer >24 h [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.59-3.28, P < 0.01], the occurrence of procedure-related major adverse events (OR 6.81, 95% CI 2.90-16.0, P < 0.01), Charlson Comorbidity Index (CCI, OR 2.39, 95% CI 1.56-3.66, P < 0.01) and its components congestive heart failure (OR 8.04, 95% CI 1.71-37.8, P < 0.01), and diabetes mellitus (OR 1.59, 95% CI 1.13-2.22, P < 0.01) were significantly associated with in-hospital death.

CONCLUSIONS

We reported in-hospital mortality rates after CA of ventricular arrhythmias in the largest multicentre, administrative dataset in Germany which can be implemented in quality management programs. Aside from comorbidities, a delayed hospital transfer to a CA performing centre is associated with an increased in-hospital mortality. This deserves further studies to determine the optimal management strategy.

Ten-year trends in catheter ablation for ventricular tachycardia vs other interventional procedures in Australia

AIMS

Major technological and procedural advancements have reinvigorated catheter ablation as adjunctive therapy for drug-refractory ventricular tachycardia (VT). We examined temporal trends in VT ablations as compared to other interventional cardiovascular procedures namely, percutaneous coronary intervention (PCI) and atrial fibrillation (AF) ablation in Australia.

METHODS AND RESULTS

A retrospective review of procedural numbers for VT ablations, AF ablations, and PCI was performed from 2008/09-2016/17 the Australian Institute of Health, Welfare and Aging (AIHW), and Medicare Australia (MA) databases. Linear regression models were fitted to compare the trends in population-adjusted procedural numbers over the 10-year period. Data from the AIHW and MA sources respectively showed that (a) PCI had a 1.3% (AIHW data P = .15) and 1.8% (MA data P < .001) population-adjusted increment per year, (b) AF ablations had a 12.7% (P < .001) and 11.7% (P < .001) per year population-adjusted increment, and (c) VT ablations showed an 18% (P < .001) and 12.7% (P < .001) per year population-adjusted increment. Growth of PCI was increasing at a lower rate than AF ablations (P < .001 for both AIHW and MA sources). Growth of VT ablation was significantly higher than AF ablations and PCI (AIHW: 18% vs 12.7% [P = .004] and 1.3% per year [P < .001]).

CONCLUSION

Catheter-based VT ablation has increased significantly in Australia over the last decade, consistent with worldwide trends, and now surpassing all ablation procedures, including AF ablation and PCI for CAD. This data highlight the provision of additional resources to match the increasing demand for VT ablation procedures in Australia.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Risk score model for predicting complications in patients undergoing ventricular tachycardia ablation: insights from the National Inpatient Sample database

AIMS

Outcome data on ventricular tachycardia (VT) ablation has been limited to few experienced centres. We sought to identify complication rates, predictors, and create a risk score model for predicting complications in patients from real-world data.

METHODS AND RESULTS

A total of 25 451 patients undergoing VT ablation from year 2006 to 2013 were identified from the National Inpatient Sample (NIS) database. The whole cohort was randomly divided into derivation cohort to derive the model and validation cohort to validate the model. Multivariate predictors of any complication were identified using regression model. Each predictor was assigned a risk score and each patient was assigned to one of the four groups (risk score in parenthesis) based on total combined risk score: Group 0 (0), Group 1 (1-5), Group 2 (6-10), and Group 3 (>11). The rate of 'any complication' and 'in-hospital mortality' in whole cohort was 14.7% and 2.8%, respectively. The predictors of any complication include chronic kidney disease, coagulopathy, chronic liver disease, stroke (cerebrovascular accident), emergency procedure, age ≥ 65 years, coronary artery disease, peripheral vascular disease, and female gender. There was a significant increase in complication rate in a linear fashion as the risk score increased. The incidence of any complications increased from 2.7% in Group 0 to 31% in Group 3. The risk score model performed well in predicting complications associated with VT ablation.

CONCLUSION

Patients with higher risk scores have significant increase in any complication and in-hospital mortality from VT ablation. The simple risk score model can help to risk stratify patients prior to VT ablation.

Comparison of Complications of Catheter Ablation for Ventricular Arrhythmias in Adults With Versus Without Structural Heart Disease

Catheter ablation (CA) is an effective treatment for ventricular arrhythmias (VA), with a potential for complications. The presence of structural heart disease (SHD) is associated with a higher complication rate although there is no data comparing CA of VA between patients with SHD and those without. We aimed to compare trends, morbidity, and mortality associated with real world practice of CA for VA (ventricular tachycardia and premature ventricular contraction) based on the presence of SHD. Using weighted sampling in the National Inpatient Sample database, we collected and compared characteristics and outcomes of patients with or without SHD that underwent CA of VA. Among 34,907 patients that underwent CA for VA (1999-2013), 18,014 (51.6%) had SHD. Major and all complications occurred among 1,135/18,014 (6.3%) and 2139/18,014 (11.9%) patients with SHD respectively compared with 355/16,893 (2.1%) and 739/16,893 (4.4%) for patients without SHD, p < 0.001 for both comparisons. Furthermore, 452/18,014 (2.51%) with SHD died versus 20/16,893 (0.12%) without SHD, p < 0.001. Heart failure was associated with an odds ratio (OR) of 3.09 for major complications (95%CI: 1.53-6.27, p = 0.002) for patients with SHD while coronary artery disease OR for major complications was 2.47 (95%CI: 1.44-4.23, p = 0.001) for patients without SHD. There was a significant increase in major complications over the 15-year study period in patients with SHD, p < 0.001. In conclusion, the presence of SHD during CA for VA increased the complication rate of major and any complications by approximately threefold for both and the hospital mortality by >20-fold compared with patients without SHD.

Early versus delayed coronary artery bypass graft surgery for patients with non-ST elevation myocardial infarction

BACKGROUND

Although coronary artery bypass graft surgery (CABG) has been proven to have mortality and morbidity benefits in patients with non-ST elevation myocardial infarction and multivessel disease, the appropriate timing of this procedure remains unclear. Therefore, we proposed a propensity score-matched analysis comparing the clinical outcomes between patients who underwent CABG within the first 48 h of admission (early CABG) and patients who underwent CABG after 48 h of admission (delayed CABG).

PATIENTS AND METHODS

Using the largest inpatient care database in the USA, the Nationwide Inpatient Sample, we identified patients with a primary diagnosis of acute myocardial infarction using the ICD 9-DM diagnosis codes. We then performed propensity score-matching analysis to control for 24 possible confounders.

RESULTS

We identified 31 969 patients in the Nationwide Inpatient Sample database with a primary diagnosis of acute myocardial infarction who underwent CABG. The mean age of the cohort was 64.5±11.5 years and 33.4% were female. After performing propensity-matching analysis, we obtained a subset of 1555 patients in each group, with a mean age of 64.7±10.1 years; the male to female ratio was ~4 : 1. The incidence of hemorrhage, shock, and cardiac, pulmonary, and renal complications was comparable between the two groups. The incidence of mortality was not statistically significant between the two groups (2% in the early CABG vs. 1.8% in the delayed CABG, P=0.695). The mortality risk factors were as follows: age more than 70 years [odds ratio (OR): 3.42, 95% confidence interval (CI): 1.85-6.34, P<0.001]; cardiogenic shock (OR: 3.22, 95% CI: 1.35-7.67, P=0.008); and mechanical circulatory support with balloon counterpulsation (OR: 2.93, 95% CI: 1.45-5.90, P=0.003).

CONCLUSION

CABG performed within 48 h of admission does not significantly increase the risk for in-hospital mortality compared with undergoing the procedure after 48 h of admission in propensity-matched patients.

Sex differences in the contemporary management of HIV patients admitted for acute myocardial infarction

BACKGROUND

Studies have reported sex differences in the management of patients with acute myocardial infarction (AMI) in the general population. This observational study is designed to evaluate whether sex differences exist in the contemporary management of human immunodeficiency virus (HIV) patients admitted for diagnosis of AMI.

HYPOTHESIS

There is no difference in management of HIV patients with AMI.

METHODS

Using the National Inpatient Sample database, we identified patients with a primary diagnosis of AMI and a secondary diagnosis of HIV. We described baseline characteristics and outcomes using NIS documentation. Our primary areas of interest were revascularization and mortality.

RESULTS

Among 2 977 387 patients presenting from 2010 to 2014 with a primary diagnosis of AMI, 10907 (0.4%) had HIV (mean age, 54.1 ± 9.3 years; n = 2043 [18.9%] female). Females were younger, more likely to be black, and more likely to have hypertension, diabetes, obesity, and anemia. Although neither males nor females were more likely to undergo coronary angiography in multivariate analysis, revascularization was performed less frequently in females than in males (45.4% vs 62.7%; P < 0.01), driven primarily by lower incidence of PCI. In a multivariate model, females were less likely to undergo revascularization (OR: 0.59, 95% CI: 0.45-0.78, P < 0.01), a finding driven solely by PCI (OR: 0.64, 95% CI: 0.49-0.83, P < 0.01). All-cause mortality was similar in both groups.

CONCLUSIONS

AMI was more common in males than females with HIV. Females with HIV were more likely to be younger and black and less likely to be revascularized by PCI.

Management of Arrhythmias in Athletes: Atrial Fibrillation, Premature Ventricular Contractions, and Ventricular Tachycardia

OPINION STATEMENT

Management of atrial fibrillation, premature ventricular contractions, and ventricular tachycardia without underlying cardiac disease or arrhythmogenic conditions differs in athletes from the general population. Athletes tend to be younger, healthier individuals with few comorbidities. Therapies that work well in the general population may not be appropriate or preferable for athletes. Management strategies include deconditioning, pharmacologic therapy, such as rate control with β-blockers or non-dihydropyridine calcium channel blockers and rhythm control with class I or class III antiarrhythmic drugs, and catheter ablation. Deconditioning is not preferred by athletes because of lost playing time. Pharmacologic therapy is well tolerated among most individuals, but is not as favorable in athletes. Rate control medications can reduce performance and β-blockers, in particular, are prohibited in many sports. Antiarrhythmic drugs are preferred over rate control with athletes, but many, especially younger athletes, may not like the idea of long-term medical therapy. Catheter ablation has been proven to be safe and efficacious, may eliminate the need for long-term medical therapy, and is supported by the major societies (AHA, ACC, ESC).

Utility of high density multielectrode mapping during ablation of scar-related ventricular tachycardia

INTRODUCTION

Multielectrode mapping catheters (MEMC) allow the performance of high resolution and density maps but the utility of these catheters in ventricular tachycardia (VT) ablation procedures has not been yet widely described. We sought to evaluate the utility of a MEMC during scar-related VT ablation procedures.

METHODS

Eighty-five consecutive scar-related VT ablation procedures were performed in 81 patients. In the first 26 procedures, a standard 3.5-mm tip linear catheter was employed for endocardial/epicardial mapping (control group). In the following 59 procedures mapping was performed with a MEMC (study group). Procedural time, LV endocardial and epicardial mapping time, complications and ablation outcomes were compared.

RESULTS

The use of the MEMC resulted in a significant shortening of the endocardial and epicardial mapping times (38 ± 15 minutes vs. 56 ± 24 minutes for endocardial LV mapping in the study and control group, respectively, P = 0.001; and 28 ± 9 minutes vs 41 ± 16 minutes, for epicardial mapping, P = 0.011) as well as the total procedural time (177 ± 53 minutes vs. 206 ± 50 minutes, respectively, P = 0.02). The mapping density was also significantly increased in the study group (mean endocardial LV points: 2,143 ± 1,419 vs. 485 ± 174, for the study and control group, respectively, P < 0.0001), specially within the scar area (49.6 ± 34 points/cm² vs. 8.4 ± 4.6 points/cm² , P < 0.001). No differences in acute and long-term follow-up outcomes were observed.

CONCLUSIONS

High-density multielectrode mapping is associated with a significant reduction of procedural and mapping times and a significant increase of mapping density without affecting outcomes in patients with scar-related VT.

Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients

BACKGROUND

Pneumothorax (PTX) is a potential complication of vascular access during cardiac implantable electronic device (CIED) procedures and is being scrutinized as a health care-acquired condition.

OBJECTIVE

The purpose of this study was to determine the trends in PTX incidence in the United Stated over a 16-year period and to determine whether PTX is associated with increased mortality after adjustment for other factors.

METHODS

Using weighted sampling in the largest inpatient health database in the United States (National Inpatient Sample), we evaluated data from patients with a primary procedure of CIED implantation from 1998 to 2013 who had at least 1 new vascular access (new or upgrade of prior CIED). The unadjusted and adjusted associations of PTX with mortality and other parameters were examined.

RESULTS

Among 3,764,703 CIED procedures, PTX occurred in 47,839 cases (1.3%). The apparent incidence of PTX peaked at 1.6% in 2012 and 2013, although this result may have been affected by a concomitant decrease of inpatient (vs outpatient) CIED. PTX was significantly associated with pulmonary complications, chest tube insertion, length of stay, and costs. Mortality was statistically higher in patients with PTX (1.2% vs 0.7%; P <.001), a relationship that remained significant in a multivariate logistic regression analysis (odds ratio 1.50, 95% confidence interval 1.36-1.65; P <.001). Age >80 years, female gender, Caucasian race, chronic obstructive pulmonary disease, and dual-chamber (vs single-chamber) device were all associated with higher odds for PTX occurrence. Placement of a chest tube was a major determinant of worse outcomes and higher costs.

CONCLUSION

PTX remains an important complication of CIED procedures and is associated with increased morbidity, mortality, and costs.

Ventricular Tachycardia Ablation in Severe Heart Failure: An International Ventricular Tachycardia Ablation Center Collaboration Analysis

BACKGROUND

Ventricular tachycardia (VT) radiofrequency ablation has been associated with reduced VT recurrence and mortality, although it is typically not considered among New York Heart Association class IV (NYHA IV) heart failure patients. We compared characteristics and VT radiofrequency ablation outcomes of those with and without NYHA IV in the International VT Ablation Center Collaboration.

METHODS AND RESULTS

NYHA II-IV patients undergoing VT radiofrequency ablation at 12 international centers were included. Clinical variables, VT recurrence, and mortality were analyzed by NYHA IV status using Kaplan-Meier analysis and Cox proportional hazard models. There were significant differences between NYHA IV (n=111) and NYHA II and III (n=1254) patients: NYHA IV had lower left ventricular ejection fraction; more had diabetes mellitus, kidney disease, cardiac resynchronization implantable cardioverter-defibrillator, and VT storm despite greater antiarrhythmic drug use (P<0.01). NYHA IV subjects required more hemodynamic support, were inducible for more and slower VTs, and were less likely to undergo final programmed stimulation. There was no significant difference in acute complications. In-hospital deaths, recurrent VT, and 1-year mortality were higher in the NYHA IV group, in the context of greater baseline comorbidities. Importantly, NYHA IV patients without recurrent VT had similar survival compared with NYHA II and III patients with recurrent VT (68% versus 73%). Early VT recurrence (≤30 days) was significantly associated with mortality, especially in NYHA IV patients.

CONCLUSIONS

Despite greater baseline comorbidities, VT radiofrequency ablation can be safely performed among NYHA IV patients. Early VT recurrence is significantly associated with subsequent mortality regardless of NYHA status. Elimination of recurrent VT in NYHA IV patients may reduce mortality to a level comparable to NYHA II and III with arrhythmia recurrence.

[Catheter ablation of ventricular arrhythmias. Complications and emergency situations]

Catheter ablation of ventricular arrhythmias is an established treatment for patients with and without structural heart disease. For patients without structural heart disease, the aim is symptomatic relief, while the ultimate goals for patients with underlying structural heart disease are reduction of ICD therapies and improved prognosis. Rates for major complications range between 6-10% in patients with structural heart disease. Vascular complications are most common; life-threatening complications (e.g., pericardial tamponade and stroke) are less frequent. Procedure-associated mortality is reported to be 0-3%. In patients with idiopathic ventricular tachycardia, the complication rate is much lower compared to patients with structural heart disease.

Sustained Ventricular Tachycardia in Apparently Normal Hearts: Medical Therapy Should be the First Step in Management

Sustained monomorphic ventricular tachycardia or repetitive premature ventricular complexes can be seen in patients with structurally normal hearts. Among these types of patients, the prognosis is predominantly benign and the treatment mostly focused on elimination of symptoms rather than improving survival or reduction of mortality. This article focuses on the pharmacologic options for management and compares them with invasive options. Based on the current literature, we demonstrate that medical therapies should be used as first-line management and favored over invasive therapies. Understanding the arrhythmia mechanism is critical in choosing the appropriate medication among the wide variety of antiarrhythmic drugs available.

Mobile thrombus on cardiac implantable electronic device leads of patients undergoing cardiac ablation: incidence, management, and outcomes

PURPOSE

The rates of cardiovascular implantable electronic device (CIED) implantations and cardiac ablation procedures are increasing worldwide. To date, the management of CIED lead thrombi in the peri-ablation period remains undefined and key clinical management questions remained unanswered. We sought to describe the clinical course and management strategies of patients with a CIED lead thrombus detected in the peri-ablative setting.

METHODS

We performed a retrospective analysis of all patients who underwent a cardiac ablation procedure at Mayo Clinic Rochester from 2000 to 2014. Patients were included in our study cohort if they had documented CIED lead thrombus noted on peri-ablation imaging studies. Electronic medical records were reviewed to determine the overall management strategy, outcomes, and embolic complications in these patients.

RESULTS

Our overall cohort included 1833 patients, with 27 (1.4 %) having both cardiac ablation procedures as well as CIED lead thrombus detected on imaging. Of these 27 patients, 21 were male (77 %), and the mean age was 59.2 years. The mean duration of follow-up was 16.5 months (range 3 days-48.3 months). Anticoagulation was an effective therapeutic strategy, with 11/14 (78.6 %) patients experiencing either resolution of the thrombus or reduction in size on re-imaging. For atrial fibrillation ablation, the most common management strategy was a deferment in ablation with initiation/intensification of anticoagulation medication. For ventricular tachycardia ablations, most procedures involved a modified approach with the use of a retrograde aortic approach to access the left ventricle. No patient had any documented embolic complications.

CONCLUSIONS

The incidence of lead thrombi in patients undergoing an ablation was small in our study cohort (1.4 %). Anticoagulation and deferral of ablation represented successful management strategies for atrial fibrillation ablation. For patients undergoing ventricular tachycardia ablation, a modified approach using retrograde aortic access to the ventricle was successful. In patients who are not on warfarin anticoagulation at the time of thrombus detection, we recommend initiation of this medication, with a goal INR of 2-3. For patients on warfarin at the time of thrombus detection, we recommend an intensification of anticoagulation with a goal INR of 3.0.