1. Assessing the Malignant Ventricular Arrhythmic Substrate in Patients With Brugada Syndrome
- Author
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Vincenzo Santinelli, Carlo Pappone, Luigi Giannelli, Josep Brugada, Gabriele Vicedomini, Giuseppe Ciconte, Zarko Calovic, Lorenzo Menicanti, Francesco Manguso, Giuseppe Della Ratta, Valerio Mecarocci, Valeria Borrelli, Paolo Pozzi, Manuel Conti, Pappone, C., Ciconte, G., Manguso, F., Vicedomini, G., Mecarocci, V., Conti, M., Giannelli, L., Pozzi, P., Borrelli, V., Menicanti, L., Calovic, Z., Della Ratta, G., Brugada, J., and Santinelli, V.
- Subjects
Adult ,Epicardial Mapping ,Male ,congenital, hereditary, and neonatal diseases and abnormalities ,medicine.medical_specialty ,Ventricular Tachyarrhythmias ,medicine.medical_treatment ,Heart Ventricles ,sudden death ,Catheter ablation ,030204 cardiovascular system & hematology ,Sudden death ,Heart Ventricle ,03 medical and health sciences ,Electrocardiography ,0302 clinical medicine ,Internal medicine ,catheter ablation ,Medicine ,Humans ,In patient ,Brugada syndrome ,cardiovascular diseases ,030212 general & internal medicine ,Prospective Studies ,mapping ,ventricular arrhythmia ,Brugada Syndrome ,programmed ventricular stimulation ,business.industry ,Substrate (chemistry) ,Middle Aged ,medicine.disease ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Human - Abstract
Background: Guidelines recommend the use of implanted cardioverter-defibrillators in patients with Brugada syndrome and induced ventricular tachyarrhythmias, but there is no evidence supporting it. Objectives: This prospective registry study was designed to explore clinical and electrophysiological predictors of malignant ventricular tachyarrhythmia inducibility in Brugada syndrome. Methods: A total of 191 consecutive selected patients with (group 1; n = 88) and without (group 2; n = 103) Brugada syndrome–related symptoms were prospectively enrolled in the registry. Patients underwent electrophysiological study and substrate mapping or ablation before and after ajmaline testing (1 mg/kg/5 min). Results: Overall, before ajmaline testing, 53.4% of patients had ventricular tachyarrhythmia inducibility, which was more frequent in group 1 (65.9%) than in group 2 (42.7%; p < 0.001). Regardless of clinical presentation, larger substrates with more fragmented long-duration ventricular potentials were found in patients with inducible arrhythmias than in patients without inducible arrhythmias (p < 0.001). One extrastimulus was used in more extensive substrates (median 13 cm2; p < 0.001), and ventricular fibrillation was the more frequently induced rhythm (p < 0.001). After ajmaline, patients without arrhythmia inducibility had arrhythmia inducibility without a difference in substrate characteristics between the 2 groups. The substrate size was the only independent predictor of inducibility (odds ratio: 4.51; 95% confidence interval: 2.51 to 8.09; p < 0.001). A substrate size of 4 cm2 best identified patients with inducible arrhythmias (area under the curve: 0.98; p < 0.001). Substrate ablation prevented ventricular tachyarrhythmia reinducibility. Conclusions: In Brugada syndrome dynamic substrate variability represents the pathophysiological basis of lethal ventricular tachyarrhythmias. Substrate size is independently associated with arrhythmia inducibility, and its determination after ajmaline identifies high-risk patients missed by clinical criteria. Substrate ablation is associated with electrocardiogram normalization and not arrhythmia reinducibility. (Epicardial Ablation in Brugada Syndrome [BRUGADA_I]; NCT02641431; Epicardial Ablation in Brugada Syndrome: An Extension Study of 200 BrS Patients; NCT03106701)
- Published
- 2018