scholarly journals 564 Controversial role of intracardiac eletrophysiology study in Brugada syndrome: analysis of a single-centre retrospective cohort study

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Claudio Licciardello ◽  
Jacopo Marazzato ◽  
Michele Golino ◽  
Francesca Seganfreddo ◽  
Federica Matteo ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Stratification ◽  
Right Ventricular ◽  
Brugada Syndrome ◽  
Type I ◽  
Drug Induced ◽  
Programmed Ventricular Stimulation ◽  
Asymptomatic Patients ◽  
Ventricular Stimulation

Abstract Aims According to European guidelines, aborted sudden cardiac death (SCD) in Brugada syndrome (BrS) is regarded as a I class recommendation for secondary prevention implantable cardioverter defibrillator (ICD). However, the risk stratification of BrS patients for primary prevention ICD still represents a clinical conundrum. Although intracardiac electrophysiology (EP) study proved useful for the selection of high-risk patients in this setting. Therefore, aim of this study was to assess all clinical and EP variables associated with the induction of VA at EP study and the rate of appropriate/inappropriate ICD interventions and/or clinical SCD events in these patients occurring at follow-up. Methods and results From 2001 to 2021, all EP studies performed in symptomatic/asymptomatic patients (46 ± 14 years, M 88%) with/without family history of SCD spontaneous/drug-induced type I pattern (TIP) on ECG and no spontaneous ventricular arrhythmias were retrospectively considered at our study centre. Clinical variables, BrS pattern, EP study data (including right ventricular site and type of stimulation protocol), and ICD interventions (DC-shocks or Anti-Tachycardia Pacing events, ATP) and/or SCD events occurring at follow-up were all evaluated. EP study was deemed positive for any polymorphic VA induced during programmed ventricular stimulation; non-sustained episodes included. ICD was routinely implanted in all patients with a positive EP study. Follow-up data were detected by the collection of medical and home-monitoring recordings at study-site level. Follow-up data were available in 50 patients (9 ± 6 years on average). Patients were generally young with few cardiovascular comorbidities. SCD history was known in 21 (42%) with a significant number of asymptomatic patients (48%). Br patterns were equally distributed in the investigated population (spontaneous and drug-induced TIP in 52% and 48%, respectively) and AF history was fairly common (16%). In the study population, EP study tested positive in 30 patients (60%): spontaneous TIP (P = 0.0518), few extrastimuli during programmed ventricular stimulation (P = 0.0015), and right ventricular stimulation at the apical site (P ≤ 0.0001) were the only variables to be clearly associated with a positive EP study in the appraised patients. At follow-up, appropriate ICD shocks were documented in 4 out of 30 implanted patients (13%) at generally 5 ± 7 years from EP study evaluation. Although three ICD interventions (75%) occurred in patients with spontaneous TIP, one patient with drug-induced TIP pattern and positive EP study referred to Emergency Department for unrelenting VT storm after roughly 13 years from ICD implantation. Inappropriate ICD interventions for fast rate AF were detected in 10% of cases. Finally, no SCD events were documented at follow up in patients with a negative EP study. Conclusions In a retrospective analysis, EP study proved useful in the risk stratification of SCD in BrS patients. A few ventricular extrastimuli delivered at the right ventricular apex seem sufficient to prompt the induction of life-threatening VA in high-risk BrS patients during EP study. Moreover, in this setting, a negative EP study seems protective against the development of VA/SCD events at follow-up. However, not only is spontaneous TIP associated with an increased risk of arrhythmic death, but a drug-induced TIP, generally regarded as a low-risk condition, might also be associated with a long-term hazard of SCD in these patients.

scholarly journals Indication and prognostic significance of programmed ventricular stimulation in asymptomatic patients with Brugada syndrome

EP Europace ◽  
2020 ◽  
Vol 22 (6) ◽  
pp. 972-979 ◽  
Author(s):  
Saori Asada ◽  
Hiroshi Morita ◽  
Atsuyuki Watanabe ◽  
Koji Nakagawa ◽  
Satoshi Nagase ◽  
...  
Keyword(s):  
High Risk ◽  
Ventricular Fibrillation ◽  
Brugada Syndrome ◽  
Event Rate ◽  
Prognostic Significance ◽  
Fragmented Qrs ◽  
Asymptomatic Patients ◽  
Ventricular Stimulation ◽  
Risk Patients

Abstract Aims To establish the indication for programmed ventricular stimulation (PVS) for asymptomatic patients with Brugada syndrome (BrS), we evaluated the prognostic significance of PVS based on abnormal electrocardiogram (ECG) markers. Methods and results One hundred and twenty-five asymptomatic patients with BrS were included. We performed PVS at two sites of the right ventricle with up to three extrastimuli [two pacing cycle lengths and minimum coupling interval (MCI) of 180 ms]. We followed the patients for 133 months and evaluated ventricular fibrillation (VF) events. Fragmented QRS (fQRS) and Tpeak-Tend (Tpe) interval were evaluated as ECG markers for identifying high-risk patients. Fragmented QRS and long Tpe interval (≥100 ms) were observed in 66 and 37 patients, respectively. Ventricular fibrillation was induced by PVS in 60 patients. During follow-up, 10 patients experienced VF events. Fragmented QRS, long Tpe interval, and PVS-induced VF with an MCI of 180 ms or up to two extrastimuli were associated with future VF events (fQRS: P = 0.015, Tpe ≥ 100 ms: P = 0.038, VF induction: P < 0.001). However, PVS-induced VF with an MCI of 200 ms was less specific (P = 0.049). The frequencies of ventricular tachyarrhythmia events during follow-up were 0%/year with no ECG markers and 0.1%/year with no VF induction. The existence of two ECG factors with induced VF was strongly associated with future VF events (event rate: 4.4%/year, P < 0.001), and the existence of one ECG factor with induced VF was also associated (event rate: 1.3%/year, P = 0.011). Conclusion We propose PVS with a strict protocol for asymptomatic patients with fQRS and/or long Tpe interval to identify high-risk patients.

Abstract 3003: Programmed Ventricular Stimulation Does Not Predict the Outcome of Patients with Arrhythmogenic Right Ventricular Cardiomyopathy (from DARVIN study)

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Domenico Corrado ◽  
Loira Leoni ◽  
Mark S Link ◽  
Hugh Calkins ◽  
Thomas Wichter ◽  
...  
Keyword(s):  
Sudden Death ◽  
Right Ventricular ◽  
Predictive Value ◽  
Arrhythmogenic Right Ventricular Cardiomyopathy ◽  
Ventricular Cardiomyopathy ◽  
Icd Therapy ◽  
Programmed Ventricular Stimulation ◽  
Ventricular Stimulation ◽  
History Of

Background: The Defibrillator in Arrhythmogenic Right Ventricular Cardiomyopathy International (DARVIN) study was a multicenter investigation that enrolled patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) who received an implantable defibrillator (ICD) for either secondary or primary prevention of sudden death. Methods: In this DARVIN substudy, we examined whether programmed ventricular stimulation (PVS) is able to predict the arrhythmic risk in a large cohort of 201 ARVC patients (133 males, 68 females, aged 36 ± 12 years) who received an ICD. Implant indications were a history of cardiac arrest in 13 (6%) patients; sustained ventricular tachycardia (VT) in 82 (41%); syncope in 42 (21%); asymptomatic nonsustained VT in 40 (20%); and a family history of sudden death in 24 (12%). PVS prior to ICD implantation was carried out in 143 of 201 patients (71%). All antiarrhythmic drugs were discontinued ≥ 5 half-lives (≥ 6 weeks for amiodarone) before the study. PVS included a minimum of 2 drive cycles length and up to 3 ventricular extrastimuli while pacing from two right ventricular sites. Results: One hundred-nine patients (76%) were inducible to either sustained VT (patients 70; 64%), with a mean cycle length of 287 ± 66ms (range 220 to 410 ms), or ventricular fibrillation/flutter (VF) (patients 39; 36%). Of 109 patients who were inducible at PVS, 56 (52%) did not experience ICD therapy during a mean follow-up of 47 ± 22 months, whereas 11 of 34 (33%) noninducible patients had appropriate ICD interventions. Overall, the positive predictive value of PVS was 48%, the negative predictive value 67%, and the test accuracy 53%. The incidence of ICD discharges on VF, which in all likelihood would have been fatal in the absence of ICD therapy, did not differ between patients who were and were not inducible at PVS (26 of 109, 24% vs 7 of 34, 21%; p=0.87), regardless of clinical presentation. The type of ventricular arrhythmia inducible at PVS did not predict VF during the follow-up. Conclusions: The presence (or absence) of an inducible arrhythmia on PVS did not correlate with subsequent appropriate ICD interventions, suggesting a limited role for PVS in arrhythmic risk stratification of ARVC patient population. A negative PVS may not indicate better prognosis.

Abstract 2640: Clinical Characteristics and Risk Stratification in Symptomatic and Asymptomatic Patients with Brugada Syndrome - Multi-center Study in Japan-

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Masahiko Takagi ◽  
Yasuhiro Yokoyama ◽  
Kazutaka Aonuma ◽  
Naohiko Aihara ◽  
Masayasu Hiraoka
Keyword(s):  
Sudden Death ◽  
Risk Stratification ◽  
Brugada Syndrome ◽  
Clinical Characteristics ◽  
Low Risk ◽  
Cardiac Events ◽  
Asymptomatic Patients ◽  
Risk Patients ◽  
Qrs Duration

Background Neither the clinical characteristics nor risk stratification of symptomatic and asymptomatic patients with Brugada syndrome have been clearly determined. We compared clinical and ECG characteristics of symptomatic and asymptomatic patients with Brugada syndrome to identify new markers for distinguishing high- from low-risk patients. Methods A total of 216 consecutive individuals with Brugada syndrome (mean age 52±14 years, 197 males) were enrolled in the Japan Idiopathic Ventricular Fibrillation Study (J-IVFS). Clinical and ECG characteristics were compared among 3 groups of patients: VF group; patients with aborted sudden death and documented VF (N=34), Syncope (Sy) group; patients with syncope without documented VF (N=70), and Asymptomatic (As) group; subjects without symptoms (N=112). Comparisons were made among the 3 groups as well as between the symptomatic (VF/Sy) and asymptomatic (As) groups. Short-term prognosis was also compared among the 3 groups, and between the VF/Sy and As groups. Results 1) Clinical characteristics: incidence of past history of AF was significantly higher in the VF and Sy groups than in the AS group (26, 26, and 12 %, respectively; [p=0.04]), though no other clinical parameters differed among the groups. 2) On resting 12-lead ECG, r-J interval (interval from QRS onset to J point) in lead V2 and QRS duration in lead V6 were highest in the VF group (104, 98, and 92 msec in V2 [p<0.001]; 106, 103, and 94 msec in V6 [p<0.0001], respectively, VF vs. Sy vs. As). 3) Positive late potential and inducibility of VF by EPS did not differ in incidence among the 3 groups. 4) Clinical follow-up: during a mean follow-up of 36±16 months, incidence of cardiac events (sudden death and/or VF) was higher in the VF/Sy groups than in the As group (29, 8, and 0 %, respectively [p<0.001]). Multivariate analysis showed that the frequencies of r-J interval ≥ 90 msec in lead V2 and QRS duration ≥ 90 msec in lead V6 were significantly higher in patients with cardiac events (p=0.02, 0.02, respectively). Conclusions In symptomatic patients, prolonged ventricular depolarization in precordial leads of the ECG was prominent in the VF group, and this sign can be used to distinguish high- from low-risk patients with Brugada syndrome.

scholarly journals Programmed Ventricular Stimulation for Risk Stratification in the Brugada Syndrome

Circulation ◽  
2016 ◽  
Vol 133 (7) ◽  
pp. 622-630 ◽  
Author(s):  
Jakub Sroubek ◽  
Vincent Probst ◽  
Andrea Mazzanti ◽  
Pietro Delise ◽  
Jesus Castro Hevia ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Brugada Syndrome ◽  
Programmed Ventricular Stimulation ◽  
Ventricular Stimulation

Abstract 636: Conduction Delay in Right Ventricle as a Marker for Identifying High-Risk Patients in Brugada Syndrome

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Atsushi Doi ◽  
Masahiko Takagi ◽  
Keiko Maeda ◽  
Hiroaki Tatsumi ◽  
Kenji Shimeno ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Stratification ◽  
Right Ventricle ◽  
Right Ventricular ◽  
Brugada Syndrome ◽  
Challenge Test ◽  
Conduction Delay ◽  
High Risk Patients ◽  
Coupling Interval ◽  
Risk Patients

BACKGROUND In Brugada syndrome (BS), abnormal conduction delay in right ventricle has been reported. However, the meaning of the conduction delay for risk stratification in BS is still unclear. OBJECTIVES To evaluate the significance of conduction delay in patients with BS as a marker for risk stratification. METHODS Twenty-four patients with BS in whom pilsicainide challenge test was performed (documented VF: N = 7, syncope: N = 7, and asymptomatic: N = 10) were paced from right ventricular apex (RVA), using a basic cycle length of 500ms (8 beats) and a single extrastimulus. A 2.5-French 16-electrode catheter was positioned into the coronary sinus and the great cardiac vein to record intracardiac electrograms on the epicardial sites in right ventricular outflow tract area (RVOT) and lateral left ventricle (l-LV). We measured the conduction time from the stimulus artifact at RVA to the epicardial ventricular electrogram at RVOT or l-LV. The conduction delay between RVA and RVOT (CD-RV) or between RVA and l-LV (CD-LV) was defined as the time interval between the ventricular response at RVOT (RV-V1V2) or at l-LV (LV-V1V2) and the stimulus coupling interval (S1S2) at RVA, respectively (CD-RV; RV-V1V2 minus S1S2, and CD-LV; LV-V1V2 minus S1S2). We also measured 12-lead ECG parameters at baseline and after pilsicainide challenge test, and evaluated the differences of the ECG parameters before and after pilsicainide challenge test. RESULTS Max CD-RV was significantly larger than max CD-LV in all patients (28±9 vs 19±7 ms, p<0.05). Max CD-RV in patients with documented VF was significantly larger than that in patients without (35±10 vs 25±7 ms, p<0.05). However, there was no significant difference in max CD-RV and CD-LV between patients with induced VF and those without (30±9 and 20±5 vs 26±7 and 21±7 ms, p=NS). There was significant positive correlation between max CD-RV and the differences in QRS duration in leads V1, V2, and V6 after pilsicainide administration (r = 0.51, 0.53, and 0.48, respectively, p<0.05). CONCLUSIONS The conduction delay in right ventricle (RV) was a useful marker for identifying high-risk patients in BS. The conduction delay at RV may be related to depolarization abnormality due to sodium channel dysfunction in BS.

scholarly journals 172: Long-term follow-up after programmed ventricular stimulation in asymptomatic patients with myocardial infarction

2013 ◽  
Vol 5 (1) ◽  
pp. 57
Author(s):  
Béatrice Brembilla-Perrot ◽  
Olivier Huttin ◽  
Bérivan Azman ◽  
Jean Marc Sellal ◽  
Pierre Yves Zinzius ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Programmed Ventricular Stimulation ◽  
Asymptomatic Patients ◽  
Ventricular Stimulation ◽  
Long Term Follow Up

scholarly journals Risk Stratification in Brugada Syndrome: Current Status and Emerging Approaches

2018 ◽  
Vol 7 (2) ◽  
pp. 79 ◽  
Author(s):  
Shohreh Honarbakhsh ◽  
Rui Providencia ◽  
Pier D Lambiase ◽  
◽  
◽  
...  
Keyword(s):  
High Risk ◽  
Sudden Cardiac Death ◽  
Risk Stratification ◽  
Brugada Syndrome ◽  
Cardiac Death ◽  
Right Ventricular Outflow Tract ◽  
Current Status ◽  
Drug Induced ◽  
Increased Risk

Brugada syndrome (BrS) is one of the most common inherited channelopathies associated with an increased risk of sudden cardiac death. Appropriate use of an ICD in high-risk patients is life-saving. However, there remains a lack of consensus on risk stratification, and even on the diagnosis of BrS itself. Some argue that people with a type 1 Brugada ECG pattern but no symptoms should not be diagnosed with BrS, and guidelines recommend observation without therapy in these patients. Others argue that the presence of a spontaneous (rather than drug-induced) type 1 ECG pattern alone is enough to label them as high-risk for arrhythmic events, particularly if syncope is also present. Syncope and a spontaneous type 1 ECG pattern are the only factors that have consistently been shown to predict ventricular arrhythmic events and sudden cardiac death. Other markers have yielded conflicting data. However, in combination they may have roles in risk scoring models. Epicardial catheter ablation in the right ventricular outflow tract has shown promise in studies as an alternative management option to an ICD, but longer follow-up is required to ensure that the ablation effect is permanent.

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