Original Article Complications of Catheter Ablation of Ventricular Tachycardia A Single-Center Experience Petr Peichl, MD, PhD*; Dan Wichterle, MD, PhD*; Ludek Pavlu, MD*; Robert Cihak, MD, PhD; Bashar Aldhoon, MD, PhD; Josef Kautzner, MD, PhD Background—Catheter ablation has become an established treatment modality for a broad spectrum of ventricular tachycardias (VTs). We analyzed incidence and predictors of major complications of VT ablation procedures in a highvolume expert center. Methods and Results—We evaluated 548 consecutive patients who underwent 722 ablation procedures, 473 (65.5%) for structural heart disease VT in the period 2006 to 2012. There were 45 (6.2%) major complications observed in 44 patients. Access site vascular complications were the most frequent (3.6%). Three patients (0.4%) had cardiac tamponade/ hemopericardium, and 5 patients (0.7%) had a thromboembolic event. No procedural deaths occurred. Procedures for structural heart disease VT versus idiopathic VT had a significantly higher complication rate (8.0% versus 2.8%; P=0.006). Similarly, patients with electrical storm (10.1% versus 5.3%; P=0.04) and nonelective procedures (8.4% versus 3.5%; P=0.007) were at higher risk of complications. On multivariate analysis, age >70 years (P=0.01), serum creatinine >115 μmol/L (P=0.0003), and individual operator (P=0.0001) were the only independent predictors of complications. Overall 30-day mortality in the structural heart disease VT group reached 5.0% (patients) and 3.6% (procedures). Death was associated with early recurrence of VT/ventricular fibrillation (P=0.003) and ablation for electrical storm (P=0.02). Conclusions—Complication rates for VT ablation are significantly lower in idiopathic VT or in elective procedures. Independent predictors of complications include age, renal insufficiency, and individual operator. Postprocedural mortality is predicted by early recurrence of VT/ventricular fibrillation and ablation for electrical storm. (Circ Arrhythm Electrophysiol. 2014;7:684-690.) Key Words: catheter ablation ◼ ventricular tachycardia
O
ver the last decade, catheter ablation has become an established treatment modality for a broad spectrum of ventricular tachycardias (VTs).1 Although it is considered a curative procedure in idiopathic VTs, the situation is more complex in patients with structural heart disease (SHD). In the vast majority, catheter ablation is indicated as adjunctive treatment when therapies from implantable cardioverter-defibrillator occur, frequently in the setting of electrical storm. In addition, the substrate for VT in patients with SHD is usually complex and often requires more extensive ablation. As a result, the incidence of major procedure-related complications has been reported higher in the latter group. Two multicenter trials2,3 that recruited consecutive VT patients after previous myocardial infarction demonstrated major complications in 8% and 10%, respectively. Periprocedural mortality reached 3.8% and 3.0%, respectively. Thus, a better understanding of procedural risks is important for selecting patients for catheter ablation for different types of VT.
Clinical Perspective on p 690
The goal of this study was to review complication rates of VT ablation procedures in a high-volume expert center. To assess determinants of complications, clinical and procedural variables or their combination were analyzed.
Methods The study included all consecutive VT catheter ablation procedures performed at our institution between August 2006 and December 2012. Occurrence of complications was evaluated 43ºC or with a rapid drop of impedance (>10–15Ω) during ablation. Radiofrequency energy was applied in the majority of cases for a maximum of 60 seconds per target site. In patients where an epicardial approach was used, coronary angiography was performed to avoid application of radiofrequency energy in the vicinity of the epicardial coronary vessels. In the region of aortic cusps, power output was set in the majority of cases at 25 W. All of these cases were guided by intracardiac echocardiography; no coronary angiography was needed to identify ostia of the coronary vessels.
Stroke/TIA
Definitions
CAD LVEF, %
Major complications were defined as those resulting in long-term disability, requiring intervention or prolonging hospitalization.
LVEDd, mm
Statistics Continuous variables were expressed as means with SDs. For the purpose of risk prediction, they were dichotomized at clinically reasonable cutoff values. Categorical variables were expressed as percentages and compared by χ2 test. Univariate association of baseline clinical and procedural characteristics with major complications was expressed as relative risk with an associated 95% confidence interval. Stepwise forward analysis of a multivariate regression model was used to assess the independent association of individual factors with complication rates. A composite scoring system based on quartile categorization of selected risk factors was used for predicting overall complication risk. A P value 60 mm
3.5
9.7
2.8
1.5–5.3
0.002
With transfusion needed
3
0
3
ICD
4.0
7.9
2.0
1.0–3.85 0.04
With conservative management
1
0
1
CRT
4.0
13.1
3.3
1.8–5.9
0.00007
13.5
3.3
1.8–5.9
0.00007
7 (2.8%)
38 (8.0%)
Serum creatinine >115 μmol/L (>1.3 mg/dL)
4.1
45 (6.2%)
Vascular access
Groin hematoma
Total
Values are counts (%). AV indicates atrioventricular; AVF, arteriovenous fistula; CPR, cardiopulmonary resuscitation; HF, heart failure; LBBB, left bundle branch block; RV, right ventricular; SHD, structural heart disease; TIA, transient ischemic event; and VT, ventricular tachycardia.
CRT indicates cardiac resynchronization therapy; ICD, implantable cardioverterdefibrillator; LVEDd, left ventricular (LV) end diastolic diameter; LVEF, LV ejection fraction; and SHD-VT, structural heart disease ventricular tachycardia.
Downloaded from http://circep.ahajournals.org/ at UNIVERSITY COLORADO on April 9, 2015
Peichl et al Complications of Ventricular Tachycardia Ablation 687 predictors of complications (Table 4). When analysis was performed with risk factors as continuous variables, LVEF appeared to be an independent predictor. Using the practically applicable risk factors, the composite risk score (range 0–9) was calculated from age, LVEF, and serum creatinine strata as a sum of risk points (Figure). For age, 0, 1, 2, and 3 risk points were assigned for each quartile: 1.3 mg/dL)
2.9
1.6–5.3
0.0003
Age >70 y
2.2
1.2–4.0
0.01
Risk Factor
extended to 30 days, 17 deaths were observed (13±9 days after ablation), resulting in early mortality rates of 3.6% per procedure and 5.0% per patient. In addition, 7 patients (2.1%) were implanted with mechanical assist devices within this period. In patients who died, the last procedure was performed for electrical storm in 10 of 17 (59%) patients as compared with the rest of the SHD-VT subgroup (25%; P=0.002). Nine of 17 (53%) patients experienced recurrent arrhythmia early (6 years. The main findings of this comprehensive analysis may be summarized as follows: (1) the incidence of major complications of catheter ablation in patients with both idiopathic and SHD-VT was 6.2%; (2) patients with idiopathic VT had significantly fewer complications than those with SHD-VT, and similarly, elective procedures were associated with lower procedural risk; (3) major life-threatening complications such as tamponade or stroke occurred in 1.5 mg/dL to be the independent predictor of complications related to catheter ablation of different arrhythmias. Advanced age was not a predictor of complications in their study, nor in a study by Inada et al18 who did not find significantly higher risk of complications in patients aged >75 years. Multivariate analysis further suggested that the operator is an important confounding factor. This is not surprising given different experience and skills of individual operators. On the contrary, the risk associated with specific operators has to be interpreted with caution. Despite the significance in multivariate analysis, the result may have been biased by unrecognized interactions between patient characteristics that were different for individual operators. Patients were not randomized between operators, and it is likely that patients at the highest risk were assigned to the most experienced operators. This is underscored by the very low observed complication rate (1.4%) found in the group of 5 operators who performed a minority of procedures (total n=71).
Thirty-Day Mortality The early mortality rate after the procedure in patients with SHD-VT is not negligible. Catheter ablation and resulting myocardial damage may have been proarrhythmic, which could have contributed to subsequent VT storm or worsening
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Peichl et al Complications of Ventricular Tachycardia Ablation 689 of heart failure. However, in severely ill patients with advanced heart failure and electrical storm, it is often difficult to differentiate between complications that are more or less related to the procedure and other adverse events because of the natural course of the disease or inability to prevent arrhythmia recurrences. In this respect, it is important to emphasize that the risk of catheter ablation in SHD is strongly dependent on patient population. For select patient populations with elective procedures, the risk of complications seems to be lower, with no 30-day mortality.6–8 However, a higher risk of complications and mortality was reported in a large series of consecutive patients, including those with electrical storm. The 7-day mortality in the Thermocool trial3 was 3%. In a series by Della Bella et al,16 the in-hospital mortality (mean 8±3 days after the procedure) reached 1.9%, which is comparable to a 7-day mortality of 1.5% in our patients after SHD-VT ablation. The 30-day mortality in our cohort was predicted by early recurrence of VT/VF necessitating repeat procedures and ablation for electrical storm. This is in concordance with a study by Carbucicchio et al19 who found that recurrent storm despite catheter ablation is strongly associated with increased cardiac mortality.
Limitations The study has several limitations. First, it is a single-center, retrospective, observational study. Second, although there were no periprocedural deaths, postprocedural mortality was not negligible. It must be acknowledged that prolonged procedures, saline overload because of ablation using open irrigation, postprocedural anemia, and worsening of renal function might have contributed to heart failure progression and early mortality. Because of the observational nature of our study, it was not possible to differentiate whether recurrent VTs were a harbinger or a causal precursor of adverse outcome. Only further prospective studies will allow determination of whether any measures (eg, hemodynamic support) can improve prognosis in these patients.
Conclusions In this series of cases, the VT ablation complication rate is significantly lower in idiopathic VT or in elective procedures. The main clinical predictors of complications include advanced age, depressed LV systolic function, and renal disease. In addition, complications of VT ablation are strongly operator-dependent. Ablation for electrical storm and early recurrence of VT/VF are the main predictors of 30-day postprocedural mortality.
Sources of Funding This study was in part supported by a research grant no. MZO 00023001 of the Ministry of Health of the Czech Republic (Research in Cardiovascular Diseases, Diabetes Mellitus, and Transplantation of Life-Preserving Organs).
Disclosures J. Kautzner is a member of advisory board for Biosense Webster, Boston Scientific, Medtronic, and St Jude Medical. He received speaker honoraria from Biosense Webster, Biotronik, Boston Scientific, GE Healthcare, Hansen Medical, Medtronic, Siemens Healthcare, and St Jude Medical. The other authors report no conflicts.
References 1. Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jaïs P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D; European Heart Rhythm Association; European Society of Cardiology; Heart Rhythm Society. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace. 2009;11:771–817. 2. Calkins H, Epstein A, Packer D, Arria AM, Hummel J, Gilligan DM, Trusso J, Carlson M, Luceri R, Kopelman H, Wilber D, Wharton JM, Stevenson W. Catheter ablation of ventricular tachycardia in patients with structural heart disease using cooled radiofrequency energy: results of a prospective multicenter study. Cooled RF Multi Center Investigators Group. J Am Coll Cardiol. 2000;35:1905–1914. 3. Stevenson WG, Wilber DJ, Natale A, Jackman WM, Marchlinski FE, Talbert T, Gonzalez MD, Worley SJ, Daoud EG, Hwang C, Schuger C, Bump TE, Jazayeri M, Tomassoni GF, Kopelman HA, Soejima K, Nakagawa H; Multicenter Thermocool VT Ablation Trial Investigators. Irrigated radiofrequency catheter ablation guided by electroanatomic mapping for recurrent ventricular tachycardia after myocardial infarction: the multicenter thermocool ventricular tachycardia ablation trial. Circulation. 2008;118:2773–2782. 4. Kozeluhova M, Peichl P, Cihak R, Wichterle D, Vancura V, Bytesnik J, Kautzner J. Catheter ablation of electrical storm in patients with structural heart disease. Europace. 2011;13:109–113. 5. Bohnen M, Stevenson WG, Tedrow UB, Michaud GF, John RM, Epstein LM, Albert CM, Koplan BA. Incidence and predictors of major complications from contemporary catheter ablation to treat cardiac arrhythmias. Heart Rhythm. 2011;8:1661–1666. 6. Tanner H, Hindricks G, Volkmer M, Furniss S, Kühlkamp V, Lacroix D, DE Chillou C, Almendral J, Caponi D, Kuck KH, Kottkamp H. Catheter ablation of recurrent scar-related ventricular tachycardia using electroanatomical mapping and irrigated ablation technology: results of the prospective multicenter Euro-VT-study. J Cardiovasc Electrophysiol. 2010;21:47–53. 7. Kuck KH, Schaumann A, Eckardt L, Willems S, Ventura R, Delacrétaz E, Pitschner HF, Kautzner J, Schumacher B, Hansen PS; VTACH Study Group. Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial. Lancet. 2010;375:31–40. 8. Reddy VY, Reynolds MR, Neuzil P, Richardson AW, Taborsky M, Jongnarangsin K, Kralovec S, Sediva L, Ruskin JN, Josephson ME. Prophylactic catheter ablation for the prevention of defibrillator therapy. N Engl J Med. 2007;357:2657–2665. 9. Dinov B, Schönbauer R, Wojdyla-Hordynska A, Braunschweig F, Richter S, Altmann D, Sommer P, Gaspar T, Bollmann A, Wetzel U, Rolf S, Piorkowski C, Hindricks G, Arya A. Long-term efficacy of single procedure remote magnetic catheter navigation for ablation of ischemic ventricular tachycardia: a retrospective study. J Cardiovasc Electrophysiol. 2012;23:499–505. 10. Yokokawa M, Desjardins B, Crawford T, Good E, Morady F, Bogun F. Reasons for recurrent ventricular tachycardia after catheter ablation of post-infarction ventricular tachycardia. J Am Coll Cardiol. 2013;61:66–73. 11. Segal OR, Chow AW, Markides V, Schilling RJ, Peters NS, Davies DW. Long-term results after ablation of infarct-related ventricular tachycardia. Heart Rhythm. 2005;2:474–482. 12. Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, Hocini M, Koplan B, Leroux L, Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG. Epicardial ventricular tachycardia ablation a multicenter safety study. J Am Coll Cardiol. 2010;55:2366–2372. 13. Tung R, Michowitz Y, Yu R, Mathuria N, Vaseghi M, Buch E, Bradfield J, Fujimura O, Gima J, Discepolo W, Mandapati R, Shivkumar K. Epicardial ablation of ventricular tachycardia: an institutional experience of safety and efficacy. Heart Rhythm. 2013;10:490–498. 14. Lü F, Eckman PM, Liao KK, Apostolidou I, John R, Chen T, Das GS, Francis GS, Lei H, Trohman RG, Benditt DG. Catheter ablation of hemodynamically unstable ventricular tachycardia with mechanical circulatory support. Int J Cardiol. 2013;168:3859–3865. 15. Bunch TJ, Darby A, May HT, Ragosta M, Lim DS, Taylor AM, DiMarco JP, Ailawadi G, Revenaugh JR, Weiss JP, Mahapatra S. Efficacy and safety of ventricular tachycardia ablation with mechanical circulatory support compared with substrate-based ablation techniques. Europace. 2012;14:709–714.
Downloaded from http://circep.ahajournals.org/ at UNIVERSITY COLORADO on April 9, 2015
690 Circ Arrhythm Electrophysiol August 2014 16. Della Bella P, Baratto F, Tsiachris D, Trevisi N, Vergara P, Bisceglia C, Petracca F, Carbucicchio C, Benussi S, Maisano F, Alfieri O, Pappalardo F, Zangrillo A, Maccabelli G. Management of ventricular tachycardia in the setting of a dedicated unit for the treatment of complex ventricular arrhythmias: long-term outcome after ablation. Circulation. 2013;127:1359–1368. 17. Tokuda M, Kojodjojo P, Epstein LM, Koplan BA, Michaud GF, Tedrow UB, Stevenson WG, John RM. Outcomes of cardiac perforation complicating catheter ablation of ventricular arrhythmias. Circ Arrhythm Electrophysiol. 2011;4:660–666.
18. Inada K, Roberts-Thomson KC, Seiler J, Steven D, Tedrow UB, Koplan BA, Stevenson WG. Mortality and safety of catheter ablation for antiarrhythmic drug-refractory ventricular tachycardia in elderly patients with coronary artery disease. Heart Rhythm. 2010;7:740–744. 19. Carbucicchio C, Santamaria M, Trevisi N, Maccabelli G, Giraldi F, Fassini G, Riva S, Moltrasio M, Cireddu M, Veglia F, Della Bella P. Catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-defibrillators: short- and long-term outcomes in a prospective single-center study. Circulation. 2008;117:462–469.
Clinical Perspective Catheter ablation is an established treatment modality for a broad spectrum of ventricular tachycardias (VTs). Although it is considered a curative procedure in idiopathic VTs, outcomes are not generally as good in structural heart disease. In structural heart disease, catheter ablation is predominantly used as an adjunctive treatment for recurrent VT in patients with implantable cardioverter-defibrillator and is often the treatment of choice for incessant VT or in electrical storms. Our study provides an update on the incidence of complications associated with VT ablation performed in a high-volume expert center. This series of cases confirmed that the complication rate in idiopathic VT is very low, and it is higher in patients with structural heart disease. The most common complications are related to vascular access. Life-threatening complications, such as tamponade or stroke, are rare. Predictors of complications include age, renal insufficiency, and individual operator. Although there was no 30-day mortality for idiopathic VTs, it reaches ≤5% in patients with structural heart disease and is predicted by early recurrence of VT/ventricular fibrillation and ablation for electrical storm. These data can help inform treatment decisions and generally support the use of catheter ablation for VT.
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Complications of Catheter Ablation of Ventricular Tachycardia: A Single-Center Experience Petr Peichl, Dan Wichterle, Ludek Pavlu, Robert Cihak, Bashar Aldhoon and Josef Kautzner Circ Arrhythm Electrophysiol. 2014;7:684-690; originally published online June 23, 2014; doi: 10.1161/CIRCEP.114.001530 Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-3149. Online ISSN: 1941-3084
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circep.ahajournals.org/content/7/4/684
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O
ver the last decade, catheter ablation has become an established treatment modality for a broad spectrum of ventricular tachycardias (VTs).1 Although it is considered a curative procedure in idiopathic VTs, the situation is more complex in patients with structural heart disease (SHD). In the vast majority, catheter ablation is indicated as adjunctive treatment when therapies from implantable cardioverter-defibrillator occur, frequently in the setting of electrical storm. In addition, the substrate for VT in patients with SHD is usually complex and often requires more extensive ablation. As a result, the incidence of major procedure-related complications has been reported higher in the latter group. Two multicenter trials2,3 that recruited consecutive VT patients after previous myocardial infarction demonstrated major complications in 8% and 10%, respectively. Periprocedural mortality reached 3.8% and 3.0%, respectively. Thus, a better understanding of procedural risks is important for selecting patients for catheter ablation for different types of VT.
Clinical Perspective on p 690
The goal of this study was to review complication rates of VT ablation procedures in a high-volume expert center. To assess determinants of complications, clinical and procedural variables or their combination were analyzed.
Methods The study included all consecutive VT catheter ablation procedures performed at our institution between August 2006 and December 2012. Occurrence of complications was evaluated 43ºC or with a rapid drop of impedance (>10–15Ω) during ablation. Radiofrequency energy was applied in the majority of cases for a maximum of 60 seconds per target site. In patients where an epicardial approach was used, coronary angiography was performed to avoid application of radiofrequency energy in the vicinity of the epicardial coronary vessels. In the region of aortic cusps, power output was set in the majority of cases at 25 W. All of these cases were guided by intracardiac echocardiography; no coronary angiography was needed to identify ostia of the coronary vessels.
Stroke/TIA
Definitions
CAD LVEF, %
Major complications were defined as those resulting in long-term disability, requiring intervention or prolonging hospitalization.
LVEDd, mm
Statistics Continuous variables were expressed as means with SDs. For the purpose of risk prediction, they were dichotomized at clinically reasonable cutoff values. Categorical variables were expressed as percentages and compared by χ2 test. Univariate association of baseline clinical and procedural characteristics with major complications was expressed as relative risk with an associated 95% confidence interval. Stepwise forward analysis of a multivariate regression model was used to assess the independent association of individual factors with complication rates. A composite scoring system based on quartile categorization of selected risk factors was used for predicting overall complication risk. A P value 60 mm
3.5
9.7
2.8
1.5–5.3
0.002
With transfusion needed
3
0
3
ICD
4.0
7.9
2.0
1.0–3.85 0.04
With conservative management
1
0
1
CRT
4.0
13.1
3.3
1.8–5.9
0.00007
13.5
3.3
1.8–5.9
0.00007
7 (2.8%)
38 (8.0%)
Serum creatinine >115 μmol/L (>1.3 mg/dL)
4.1
45 (6.2%)
Vascular access
Groin hematoma
Total
Values are counts (%). AV indicates atrioventricular; AVF, arteriovenous fistula; CPR, cardiopulmonary resuscitation; HF, heart failure; LBBB, left bundle branch block; RV, right ventricular; SHD, structural heart disease; TIA, transient ischemic event; and VT, ventricular tachycardia.
CRT indicates cardiac resynchronization therapy; ICD, implantable cardioverterdefibrillator; LVEDd, left ventricular (LV) end diastolic diameter; LVEF, LV ejection fraction; and SHD-VT, structural heart disease ventricular tachycardia.
Downloaded from http://circep.ahajournals.org/ at UNIVERSITY COLORADO on April 9, 2015
Peichl et al Complications of Ventricular Tachycardia Ablation 687 predictors of complications (Table 4). When analysis was performed with risk factors as continuous variables, LVEF appeared to be an independent predictor. Using the practically applicable risk factors, the composite risk score (range 0–9) was calculated from age, LVEF, and serum creatinine strata as a sum of risk points (Figure). For age, 0, 1, 2, and 3 risk points were assigned for each quartile: 1.3 mg/dL)
2.9
1.6–5.3
0.0003
Age >70 y
2.2
1.2–4.0
0.01
Risk Factor
extended to 30 days, 17 deaths were observed (13±9 days after ablation), resulting in early mortality rates of 3.6% per procedure and 5.0% per patient. In addition, 7 patients (2.1%) were implanted with mechanical assist devices within this period. In patients who died, the last procedure was performed for electrical storm in 10 of 17 (59%) patients as compared with the rest of the SHD-VT subgroup (25%; P=0.002). Nine of 17 (53%) patients experienced recurrent arrhythmia early (6 years. The main findings of this comprehensive analysis may be summarized as follows: (1) the incidence of major complications of catheter ablation in patients with both idiopathic and SHD-VT was 6.2%; (2) patients with idiopathic VT had significantly fewer complications than those with SHD-VT, and similarly, elective procedures were associated with lower procedural risk; (3) major life-threatening complications such as tamponade or stroke occurred in 1.5 mg/dL to be the independent predictor of complications related to catheter ablation of different arrhythmias. Advanced age was not a predictor of complications in their study, nor in a study by Inada et al18 who did not find significantly higher risk of complications in patients aged >75 years. Multivariate analysis further suggested that the operator is an important confounding factor. This is not surprising given different experience and skills of individual operators. On the contrary, the risk associated with specific operators has to be interpreted with caution. Despite the significance in multivariate analysis, the result may have been biased by unrecognized interactions between patient characteristics that were different for individual operators. Patients were not randomized between operators, and it is likely that patients at the highest risk were assigned to the most experienced operators. This is underscored by the very low observed complication rate (1.4%) found in the group of 5 operators who performed a minority of procedures (total n=71).
Thirty-Day Mortality The early mortality rate after the procedure in patients with SHD-VT is not negligible. Catheter ablation and resulting myocardial damage may have been proarrhythmic, which could have contributed to subsequent VT storm or worsening
Downloaded from http://circep.ahajournals.org/ at UNIVERSITY COLORADO on April 9, 2015
Peichl et al Complications of Ventricular Tachycardia Ablation 689 of heart failure. However, in severely ill patients with advanced heart failure and electrical storm, it is often difficult to differentiate between complications that are more or less related to the procedure and other adverse events because of the natural course of the disease or inability to prevent arrhythmia recurrences. In this respect, it is important to emphasize that the risk of catheter ablation in SHD is strongly dependent on patient population. For select patient populations with elective procedures, the risk of complications seems to be lower, with no 30-day mortality.6–8 However, a higher risk of complications and mortality was reported in a large series of consecutive patients, including those with electrical storm. The 7-day mortality in the Thermocool trial3 was 3%. In a series by Della Bella et al,16 the in-hospital mortality (mean 8±3 days after the procedure) reached 1.9%, which is comparable to a 7-day mortality of 1.5% in our patients after SHD-VT ablation. The 30-day mortality in our cohort was predicted by early recurrence of VT/VF necessitating repeat procedures and ablation for electrical storm. This is in concordance with a study by Carbucicchio et al19 who found that recurrent storm despite catheter ablation is strongly associated with increased cardiac mortality.
Limitations The study has several limitations. First, it is a single-center, retrospective, observational study. Second, although there were no periprocedural deaths, postprocedural mortality was not negligible. It must be acknowledged that prolonged procedures, saline overload because of ablation using open irrigation, postprocedural anemia, and worsening of renal function might have contributed to heart failure progression and early mortality. Because of the observational nature of our study, it was not possible to differentiate whether recurrent VTs were a harbinger or a causal precursor of adverse outcome. Only further prospective studies will allow determination of whether any measures (eg, hemodynamic support) can improve prognosis in these patients.
Conclusions In this series of cases, the VT ablation complication rate is significantly lower in idiopathic VT or in elective procedures. The main clinical predictors of complications include advanced age, depressed LV systolic function, and renal disease. In addition, complications of VT ablation are strongly operator-dependent. Ablation for electrical storm and early recurrence of VT/VF are the main predictors of 30-day postprocedural mortality.
Sources of Funding This study was in part supported by a research grant no. MZO 00023001 of the Ministry of Health of the Czech Republic (Research in Cardiovascular Diseases, Diabetes Mellitus, and Transplantation of Life-Preserving Organs).
Disclosures J. Kautzner is a member of advisory board for Biosense Webster, Boston Scientific, Medtronic, and St Jude Medical. He received speaker honoraria from Biosense Webster, Biotronik, Boston Scientific, GE Healthcare, Hansen Medical, Medtronic, Siemens Healthcare, and St Jude Medical. The other authors report no conflicts.
References 1. Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jaïs P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D; European Heart Rhythm Association; European Society of Cardiology; Heart Rhythm Society. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace. 2009;11:771–817. 2. Calkins H, Epstein A, Packer D, Arria AM, Hummel J, Gilligan DM, Trusso J, Carlson M, Luceri R, Kopelman H, Wilber D, Wharton JM, Stevenson W. Catheter ablation of ventricular tachycardia in patients with structural heart disease using cooled radiofrequency energy: results of a prospective multicenter study. Cooled RF Multi Center Investigators Group. J Am Coll Cardiol. 2000;35:1905–1914. 3. Stevenson WG, Wilber DJ, Natale A, Jackman WM, Marchlinski FE, Talbert T, Gonzalez MD, Worley SJ, Daoud EG, Hwang C, Schuger C, Bump TE, Jazayeri M, Tomassoni GF, Kopelman HA, Soejima K, Nakagawa H; Multicenter Thermocool VT Ablation Trial Investigators. Irrigated radiofrequency catheter ablation guided by electroanatomic mapping for recurrent ventricular tachycardia after myocardial infarction: the multicenter thermocool ventricular tachycardia ablation trial. Circulation. 2008;118:2773–2782. 4. Kozeluhova M, Peichl P, Cihak R, Wichterle D, Vancura V, Bytesnik J, Kautzner J. Catheter ablation of electrical storm in patients with structural heart disease. Europace. 2011;13:109–113. 5. Bohnen M, Stevenson WG, Tedrow UB, Michaud GF, John RM, Epstein LM, Albert CM, Koplan BA. Incidence and predictors of major complications from contemporary catheter ablation to treat cardiac arrhythmias. Heart Rhythm. 2011;8:1661–1666. 6. Tanner H, Hindricks G, Volkmer M, Furniss S, Kühlkamp V, Lacroix D, DE Chillou C, Almendral J, Caponi D, Kuck KH, Kottkamp H. Catheter ablation of recurrent scar-related ventricular tachycardia using electroanatomical mapping and irrigated ablation technology: results of the prospective multicenter Euro-VT-study. J Cardiovasc Electrophysiol. 2010;21:47–53. 7. Kuck KH, Schaumann A, Eckardt L, Willems S, Ventura R, Delacrétaz E, Pitschner HF, Kautzner J, Schumacher B, Hansen PS; VTACH Study Group. Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial. Lancet. 2010;375:31–40. 8. Reddy VY, Reynolds MR, Neuzil P, Richardson AW, Taborsky M, Jongnarangsin K, Kralovec S, Sediva L, Ruskin JN, Josephson ME. Prophylactic catheter ablation for the prevention of defibrillator therapy. N Engl J Med. 2007;357:2657–2665. 9. Dinov B, Schönbauer R, Wojdyla-Hordynska A, Braunschweig F, Richter S, Altmann D, Sommer P, Gaspar T, Bollmann A, Wetzel U, Rolf S, Piorkowski C, Hindricks G, Arya A. Long-term efficacy of single procedure remote magnetic catheter navigation for ablation of ischemic ventricular tachycardia: a retrospective study. J Cardiovasc Electrophysiol. 2012;23:499–505. 10. Yokokawa M, Desjardins B, Crawford T, Good E, Morady F, Bogun F. Reasons for recurrent ventricular tachycardia after catheter ablation of post-infarction ventricular tachycardia. J Am Coll Cardiol. 2013;61:66–73. 11. Segal OR, Chow AW, Markides V, Schilling RJ, Peters NS, Davies DW. Long-term results after ablation of infarct-related ventricular tachycardia. Heart Rhythm. 2005;2:474–482. 12. Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, Hocini M, Koplan B, Leroux L, Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG. Epicardial ventricular tachycardia ablation a multicenter safety study. J Am Coll Cardiol. 2010;55:2366–2372. 13. Tung R, Michowitz Y, Yu R, Mathuria N, Vaseghi M, Buch E, Bradfield J, Fujimura O, Gima J, Discepolo W, Mandapati R, Shivkumar K. Epicardial ablation of ventricular tachycardia: an institutional experience of safety and efficacy. Heart Rhythm. 2013;10:490–498. 14. Lü F, Eckman PM, Liao KK, Apostolidou I, John R, Chen T, Das GS, Francis GS, Lei H, Trohman RG, Benditt DG. Catheter ablation of hemodynamically unstable ventricular tachycardia with mechanical circulatory support. Int J Cardiol. 2013;168:3859–3865. 15. Bunch TJ, Darby A, May HT, Ragosta M, Lim DS, Taylor AM, DiMarco JP, Ailawadi G, Revenaugh JR, Weiss JP, Mahapatra S. Efficacy and safety of ventricular tachycardia ablation with mechanical circulatory support compared with substrate-based ablation techniques. Europace. 2012;14:709–714.
Downloaded from http://circep.ahajournals.org/ at UNIVERSITY COLORADO on April 9, 2015
690 Circ Arrhythm Electrophysiol August 2014 16. Della Bella P, Baratto F, Tsiachris D, Trevisi N, Vergara P, Bisceglia C, Petracca F, Carbucicchio C, Benussi S, Maisano F, Alfieri O, Pappalardo F, Zangrillo A, Maccabelli G. Management of ventricular tachycardia in the setting of a dedicated unit for the treatment of complex ventricular arrhythmias: long-term outcome after ablation. Circulation. 2013;127:1359–1368. 17. Tokuda M, Kojodjojo P, Epstein LM, Koplan BA, Michaud GF, Tedrow UB, Stevenson WG, John RM. Outcomes of cardiac perforation complicating catheter ablation of ventricular arrhythmias. Circ Arrhythm Electrophysiol. 2011;4:660–666.
18. Inada K, Roberts-Thomson KC, Seiler J, Steven D, Tedrow UB, Koplan BA, Stevenson WG. Mortality and safety of catheter ablation for antiarrhythmic drug-refractory ventricular tachycardia in elderly patients with coronary artery disease. Heart Rhythm. 2010;7:740–744. 19. Carbucicchio C, Santamaria M, Trevisi N, Maccabelli G, Giraldi F, Fassini G, Riva S, Moltrasio M, Cireddu M, Veglia F, Della Bella P. Catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-defibrillators: short- and long-term outcomes in a prospective single-center study. Circulation. 2008;117:462–469.
Clinical Perspective Catheter ablation is an established treatment modality for a broad spectrum of ventricular tachycardias (VTs). Although it is considered a curative procedure in idiopathic VTs, outcomes are not generally as good in structural heart disease. In structural heart disease, catheter ablation is predominantly used as an adjunctive treatment for recurrent VT in patients with implantable cardioverter-defibrillator and is often the treatment of choice for incessant VT or in electrical storms. Our study provides an update on the incidence of complications associated with VT ablation performed in a high-volume expert center. This series of cases confirmed that the complication rate in idiopathic VT is very low, and it is higher in patients with structural heart disease. The most common complications are related to vascular access. Life-threatening complications, such as tamponade or stroke, are rare. Predictors of complications include age, renal insufficiency, and individual operator. Although there was no 30-day mortality for idiopathic VTs, it reaches ≤5% in patients with structural heart disease and is predicted by early recurrence of VT/ventricular fibrillation and ablation for electrical storm. These data can help inform treatment decisions and generally support the use of catheter ablation for VT.
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Complications of Catheter Ablation of Ventricular Tachycardia: A Single-Center Experience Petr Peichl, Dan Wichterle, Ludek Pavlu, Robert Cihak, Bashar Aldhoon and Josef Kautzner Circ Arrhythm Electrophysiol. 2014;7:684-690; originally published online June 23, 2014; doi: 10.1161/CIRCEP.114.001530 Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-3149. Online ISSN: 1941-3084
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