Role of programmed ventricular stimulation in patients with idiopathic dilated cardiomyopathy and documented sustained ventricular tachyarrhythmias: inducibility and prognostic value in 102 patients

Abstract

The role of programmed ventricular stimulation (PVS) in patients at high risk of sudden death related to idiopathic dilated cardiomyopathy (DCM) is still controversial. The possible reason is that most study series have been too small or that only a few patients had documented sustained ventricular tachyarrhythmias. This study therefore, looked at PVS performed in 102 patients with DCM and documented sustained ventricular tachycardia (VT; n = 63) or ventricular fibrillation (VF; n = 39). Sustained VT was induced in 27 of 63 patients (43%) with documented sustained VT and in 14 of 39 patients (36%) with documented VF (ns). VF was induced in nine patients (14%) with a history of sustained VT and in seven (18%) with a history of VF (ns). At a mean follow-up of 32 +/- 15 months, sudden death occurred in 14 (14%) patients, a rate similar in both patients with documented VT and VF (ns). Incidence of sudden death at 36 months was 6% in patients with inducible sustained VT/VF compared to 29% in patients without inducible VT/VF (P < 0.05). A favourable drug regimen (response to drug and no intolerable side effects) was obtained by serial drug testing in 25 of all 102 patients (25%). A cardioverter defibrillator (ICD) was implanted in 32 patients, in 63% of whom discharges were observed during 18 +/- 11 months of follow-up; only one patient (3%) died suddenly. Thus, in patients with DCM, there was no relationship between documented and inducible ventricular tachyarrhythmias, and initiation of sustained VT or VF had little prognostic value for the prediction of subsequent sudden death. Wherever antiarrhythmic drug therapy was of limited value, implantation of an ICD may improve the prognosis of these high risk patients.

Comparison of Ventricular Inducibility with Late Gadolinium Enhancement and Myocardial Inflammation in Endomyocardial Biopsy in Patients with Dilated Cardiomyopathy

“…Therefore, electrophysiological analysis employing PVS along with contrast-enhanced MRI may serve as helpful diagnostic tool in selected patients to assess their individual risk for sudden cardiac death [17, 21, 23]. Deeper evaluation is possible by electroanatomical mapping during eletrophysiological examinations, which may also help to characterize arrhythmogenic sites within the ventricle to enable an ablative therapy of ventricular arrhythmias if necessary during the course of the disease [5, 19, 20].…”

“…However, these reported collectives have only been characterized by their reduced LVEF and the exclusion of relevant coronary artery disease, while other non-invasive and invasive diagnostic tools, e.g. biopsy results, were not included [17, 21–23]. To our knowledge, the impact of endomyocardial biopsy (EMB) and its significance in the risk assessment of NIDCM patients has not been described yet.…”

Risk Stratification for Sudden Cardiac Death in Dilated Cardiomyopathy Using Microvolt-Level T-Wave Alternans

“…3 Therefore, the prevention of SCD in patients with DCM has been the therapeutic target. Electrophysiological (EP) testing has not been helpful in predicting the arrhythmic risk stratification in patients with DCM 21,22 and to date, a variety of noninvasive tests have been proposed for risk stratification, including echocardiography, Holter monitoring, SAECG, QTd, and heart rate variability (HRV). 17,[23][24][25][26][27][28] However, previous methods of risk stratification in patients with DCM have had limited value in the evaluation of high-risk patients.…”

“…9 In patients with post myocardial infarction, invasive EP testing is the standard procedure for risk stratification, 29 but this procedure has not been helpful in predicting the DCM patients at high risk for SCD. 21,22 Therefore, identification of these high-risk patients before they experience a major arrhythmic event will have the greatest impact on the problem of SCD in patients with DCM and to this end a variety of noninvasive testing methods, such as echocardiography, Holter monitoring, SAECG, QTd, and HRV, have been developed, but have had limited success. 17,23,24,[26][27][28] Hohnloser et al showed that measuring TWA compared favorably with both invasive EP testing and the other noninvasive risk assessment methods in predicting recurrence of ventricular tachyarrhythmias in ICD recipients with an old myocardial infarction.…”

Clinical Characteristics of Induced Nonclinical Ventricular Tachycardia in Nonischemic Cardiomyopathy.

“…7,20,21) However, other reports suggest that EPS is of limited value for arrhythmia risk evaluation in idiopathic dilated cardiomyopathy. 22,23) Milner, et al found no difference in arrhythmia recurrence between patients with and without inducible ventricular tachyarrhythmias in an initial study. Furthermore, arrhythmia suppression during serial drug testing did not predict outcome; arrhythmia recurred in 5 of 9 patients in whom arrhythmias had been suppressed.…”