Catheter Ablation for VF Storm After MI

Apr 16, 2019
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Authors:
Komatsu Y, Hocini M, Nogami A, et al.
Citation:
Catheter Ablation of Refractory Ventricular Fibrillation Storm After Myocardial Infarction: A Multicenter Study. Circulation 2019;Apr 1:[Epub ahead of print].
Summary By:
Fred Morady, MD, FACC

Study Questions:

How effective is radiofrequency catheter ablation (RFCA) for treatment of ventricular fibrillation (VF) storm?

Methods:

This was a multicenter, retrospective study of 110 patients (mean age 65 years, mean ejection fraction 31%) who underwent RFCA because of VF storm during either the first week post-infarction (43 patients), 1 week-6 months post-infarction (48 patients), or >6 months post-infarction (19 patients). All patients experienced ≥3 separate episodes of VF within 24 hours refractory to medications, and to circulatory support and/or coronary revascularization and/or deep sedation. Premature ventricular complexes (PVCs) that triggered episodes of VF were targeted for ablation. Pacing maneuvers and isoproterenol or epinephrine infusion were used to provoke PVCs if they did not occur spontaneously. The endpoint of ablation was elimination of all clinical triggering PVCs.

Results:

The PVC site of origin was within the infarction scar in 80% of patients and at the scar border zone in 14% of patients. A Purkinje potential preceded the sinus QRS complex and the PVC in 90% of patients. During the post-ablation hospitalization, 84% of patients had no further VF storms. In-hospital mortality was 27%. During a median of 3.7 years of follow-up, VF storm recurred in only one patient and all-cause mortality was 36%.

Conclusions:

In post-infarction patients with VF storm, RFCA of the triggering PVCs often is effective in preventing further episodes of VF.

Perspective:

This study provides a realistic estimate of the efficacy of RFCA for suppressing VF storms in post-infarction patients. It is likely that in-patient mortality would have been much higher than 27% had RFCA not been as effective as it was. It is useful to know that the triggering PVCs originate in the Purkinje system and are closely related to the infarction scar. This suggests that if precise mapping of the VF triggers is not feasible, a possible option would be to target all sites within a scar and its border zone at which a Purkinje potential precedes the QRS complex during sinus rhythm.

Keywords: Arrhythmias, Cardiac, Catheter Ablation, Epinephrine, Hospital Mortality, Myocardial Infarction, Myocardial Revascularization, Isoproterenol, Secondary Prevention, Stroke Volume, Ventricular Fibrillation, Ventricular Premature Complexes


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