Non-revascularized chronic total occlusions impact on substrate and post-ablation results in drug-refractory electrical storm

Abstract

Background and aimsThere is limited data concerning the effect of non-revascularized chronic total occlusions (NR-CTOs) after VT ablation. This study sought to evaluate the impact of NR-CTOs after ablation for electrical storm (ES).MethodsPost-hoc retrospective analysis of data regarding 64 consecutive post-myocardial infarction patients (out of which 12 patients with NR-CTOs and 52 without NR-CTOs) undergoing substrate ablation for ES with an available median follow-up of 37.53 (7.25–64.65) months. Ablation result was assessed by inducibility of sustained monomorphic VT (SMVT) during final programmed ventricular stimulation (PVS). The primary endpoints were all-cause mortality and VT/VF recurrences after ablation, respectively, stratified by the presence of NR-CTOs. The secondary endpoint was to assess the predictive effect of NR-CTOs on all-cause mortality and VT/VF recurrences in relation to other relevant prognostic factors.ResultsAt baseline, the presence of NR-CTOs was associated with higher bipolar BZ-to-total scar ratio (72.4% ± 17.9% vs. 52% ± 37.7%, p = 0.022) and more failure to eliminate the clinical VT (25% (3) vs. 0% (0), p < 0.001). During follow-up, overall all-cause mortality and recurrences were more frequent in the NR-CTO subgroup (75% (9) vs. 19.2% (10), log rank p = 0.003 and 58.3% vs. 23.1% (12), log rank p = 0.042 respectively). After adjusting for end-procedural residual SMVT inducibility, NR-CTOs predicted death during follow-up (HR 3.380, p = 0.009) however not recurrence (HR 1.986, p = 0.154).ConclusionsNR-CTO patients treated by RFCA for drug-refractory ES demonstrated a higher ratio of BZ-to-total-scar area. In this analysis, NR-CTO was associated with worse acute procedural results and may as well impact long-term outcomes which should be further assessed in larger patient populations.

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

“…This retrospective study is based on a monocentric longitudinal analysis of baseline and post-procedural characteristics of consecutive ES patients, as described in previously published papers [ 19 , 20 ]. A minimum of three separate episodes of sustained ventricular monomorphic tachycardia (SMVT) treated by adequate ICD therapies in a 24 h interval refractory to medical antiarrhythmic (AAD) treatment and without reversible triggers [ 21 , 22 , 23 ].…”

Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC—endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society

“…96 In patients with cCAD but no STEMI, the potential benefit of (complete) revascularization should be carefully weighed against risk. 123 , 124 Noteworthy, MSVT is rarely caused by ischaemia, 125 and ischaemic evaluations in patients with monomorphic VT storm without ACS did not improve procedural outcomes or mortality after ablation. 126 …”