Is it possible to predict mortality and recurrence of VT afterablation? PAINESD risk score applicability vs new predictors

Abstract

Funding Acknowledgements Type of funding sources: None. Introduction Catheter ablation (CA) prevents ventricular tachycardia (VT) recurrences in patients (pts) with structural heart disease (SHD), and might have a favorable outcome, but is associated with severe short-term complications. Identification of pts at high risk of periprocedural acute haemodynamic decompensation has important implications at procedural planning. The PAINESD risk score is a promising tool to predict VT ablation procedure-related mortality. Aim To evaluate the accuracy of the PAINESD risk score to predict short-term mortality after structural VT ablation and to compare it with other conventional clinical predictors. Methods Prospective, observational, single-centre study of consecutive pts with SHD (ischemic or nonischemic), referred for VT-CA. High-density substrate maps were collected, through endocardial, epicardial or combined endo-epicardial approaches according to clinical data and operator preference. The primary endpoint was 30-day mortality or hemodynamic decompensation. Univariate Cox regression analysis was used to identify relevant clinical predictors and to compare them with the PAINESD risk score. Multivariable Cox proportional hazards regression models were used to estimate predictors of 30-day mortality. Results A total of 102 pts with SHD referred for VT ablation were evaluated(mean age: 67±11 years, 94% male, 78.4% in NYHA class I-II; mean LVEF was 34±11%). The baseline PAINESD risk score was 12.39±5.8, 19.6% at low risk, 36.3% at intermediate risk and 27.5% at high risk of adverse events. Overall 30-day mortality was 4.9%. The PAINESD did not predict 30-days mortality or hemodynamic decompensation (p= 0.93). Indeed, a non- significant trend to higher short and long-term mortality was noticed in high-risk score pts – Figure 1. On univariate analysis age>65 years (p=0.019), LVEF <35% (p=0.049), body mass index<28kg/m2 (p=0.019), CKD (p=0.001) and previous VT ablation (p=0.022) were prognostic predictors. On multivariate analysis, only LVEF<35% (HR2.225; CI95% 1.004-4-774,p=0.038) and CKD (HR 3.35; CI95%: 1.31-8.51, p=0.011) were independent predictors of short-term prognosis. Conclusions In our population, LVEF<35% and CKD were the strongest predictors of short-term mortality. PAINESD risk score was not accurate in predicting adverse events. New score systems must be derived for prognostic stratification in this population, incorporating the reduction on the actual short-term event rates after VT ablation.

Periprocedural acute haemodynamic decompensation during substrate-based ablation of scar-related ventricular tachycardia: a rare and unpredictable event

“…Two studies were published on patients undergoing CA of SHD-related VT with comparable results to ours. In the study by Martins et al 28 involving 102 patients, the PAINESD score did not predict early mortality or haemodynamic decompensations. In another study by Della et al ., 29 intraprocedural AHD occurred in only 6 among 528 patients (1.1%).…”

Novel use of an irrigated ablation catheter to monitor real‐time hemodynamics during ablation

“…For example, Santengeli et al 11 reported that specific risk factors including COPD and diabetes mellitus predicted hemodynamic compromise up to 30 days after ablation and integrated these into the PAINSED score. However, subsequent reports did not clearly corroborate these findings 12 . Interestingly, Santangeli et al 11 observed that elevated capillary wedge pressures (PCWP) did not uniformly increase before hemodynamic compromise.…”

“…However, subsequent reports did not clearly corroborate these findings. 12 Interestingly, Santangeli et al 11 observed that elevated capillary wedge pressures (PCWP) did not uniformly increase before hemodynamic compromise. However, measurement of LVEDP and incorporation of hemodynamic trends might better ascertain the need for an optimal type of LV rescue therapy in the case of compromise.…”

MSA-VT Score for Assessment of Long-Term Prognosis after Electrical Storm Ablation

“…According to PAINESD, elderly diabetic patients with ICM and low LVEF that develop ES and HF have the highest risk of developing cardiogenic shock. Subsequent studies have indicated its ability to also predict mortality VT ablation, yet certain studies have reported conflicting results regarding its accuracy, particularly regarding recurrences [ 32 , 33 , 34 ]. Existing data demonstrate different clinical trajectories in Kaplan–Meier or Cox regression in different PAINESD classes, yet no ROC curve analyses are available.…”