Assessing the Malignant Ventricular Arrhythmic Substrate in Patients With Brugada Syndrome.

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).

• Authors: Carlo Pappone, Giuseppe Ciconte, Francesco Manguso, Gabriele Vicedomini, Valerio Mecarocci, Manuel Conti, Luigi Giannelli, Paolo Pozzi, Valeria Borrelli, Lorenzo Menicanti, Zarko Calovic, Giuseppe Della Ratta, Josep Brugada, Vincenzo Santinelli
• Journal: Journal of the American College of Cardiology (J Am Coll Cardiol) Vol. 71 Issue 15 Pg. 1631-1646 (04 17 2018) ISSN: 1558-3597 [Electronic] United States
• PMID: 29650119 (Publication Type: Journal Article)
• Copyright: Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Topics

• Adult
• Brugada Syndrome (physiopathology)
• Electrocardiography
• Epicardial Mapping
• Female
• Heart Ventricles (physiopathology)
• Humans
• Male
• Middle Aged
• Prospective Studies