Ventricular tachycardia (VT) is a marker for increased mor-tality and can reduce quality of life in patients who have
implanted cardioverter defibrillators (ICDs) and structural heart disease.1,2 Radiofrequency catheter ablation is an accepted ther-apy to reduce episodes of drug-refractory VT, but recurrences are not uncommon, despite acutely successful ablation.3,4 The opti-mal duration for monitoring in hospital after ablation is not clear. Although hospital stays are often short in uncomplicated patients, we have observed several patients who needed further ablation because of early recurrences.5 Others have observed that VT, which is not inducible at the end of the procedure, is again induc-ible within a few days in a substantial number of patients, suggest-ing lesion healing.6 It seems likely that there are patients who are at risk for early recurrence and who may benefit from prolonged monitoring for recurrence and consideration of early repeat abla-tion. The aims of this study were to identify potential markers of early recurrence and assess the prognosis of these patients.
Clinical Perspective on p 888
MethodsPatient CharacteristicsA consecutive series of 370 patients (313 men; aged 63.0±13.2 years) who underwent their first radiofrequency ablation for sustained monomorphic VT associated with structural heart disease at our in-stitution from 2008 to 2012 were included. All patients underwent physical examination, 12-lead electrocardiography, chest x-ray film, and transthoracic echocardiography. Estimated glomerular filtration rate (eGFR) was calculated from the chronic kidney disease–epide-miology) creatinine equation.7 Heart disease was classified as isch-emic cardiomyopathy or nonischemic heart disease, including dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, myocarditis, val-vular heart disease, and congenital heart disease or unspecified cardio-myopathy.8 Each patient gave written informed consent. Studies and data collection were performed according to protocols approved by the Human Research Committee of Brigham and Women’s Hospital.
Electrophysiological Study and AblationProcedures were performed either under conscious sedation or gen-eral anesthesia. Using femoral venous and arterial access, multipolar
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org DOI: 10.1161/CIRCEP.114.001461
Original Article
Background—Catheter ablation for ventricular tachycardia (VT) from structural heart disease has a significant risk of recurrence, but the optimal duration for in-hospital monitoring is not defined. This study assesses the timing, correlates, and prognostic significance of early VT recurrence after ablation.
Methods and Results—Of 370 patients (313 men; aged 63.0±13.2 years) who underwent a first radiofrequency ablation for sustained monomorphic VT associated with structural heart disease from 2008 to 2012, sustained VT recurred in 81 patients (22%) within 7 days. In multivariable analysis, early recurrence was associated with New York Heart Association classification ≥III (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.03–3.48; P=0.04), dilated cardiomyopathy (OR 1.93, 95% CI 1.03–3.57; P=0.04), prevalence of VT storm before the procedure (OR 2.62, 95% CI 1.48–4.65; P=0.001), a greater number of induced VTs (OR 1.24, 95% CI 1.07–1.45; P=0.006), and acute failure or no final induction test (OR 1.88, 95% CI 1.03–3.40; P=0.04). During a median of 2.5 (1.2, 4.0) years of follow-up, early VT recurrence was an independent correlates of mortality (hazard ratio 2.59, 95% CI 1.52–4.34; P=0.0005).
Conclusions—Patients who have early recurrences of VT after ablation are a high risk group who may be identifiable from their clinical profile. Further study is warranted to define the optimal treatment strategies for this patient group. (Circ Arrhythm Electrophysiol. 2014;7:883-888.)
Received January 14, 2014; accepted July 13, 2014.From the Arrhythmia Unit, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA.Guest Editor for this article was Gerhard Hindricks, MD.The Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.114.001461/-/DC1.Correspondence to William G. Stevenson, MD, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. E-mail
Correlates and Prognosis of Early Recurrence After Catheter Ablation for Ventricular
Tachycardia due to Structural Heart DiseaseKoichi Nagashima, MD, PhD; Eue-Keun Choi, MD, PhD; Usha B. Tedrow, MD, MSc;
Bruce A. Koplan, MD, MPH; Gregory F. Michaud, MD; Roy M. John, MD, PhD; Laurence M. Epstein, MD; Michifumi Tokuda, MD, PhD; Keiichi Inada, MD, PhD;
Saurabh Kumar, MD, PhD; Kaity Y. Lin, MD; Chirag R. Barbhaiya, MD; Jason S. Chinitz, MD; Alan D. Enriquez, MD; Alan F. Helmbold, DO; William G. Stevenson, MD
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electrode catheters were positioned in the right ventricular apex and the His bundle region. Programmed ventricular stimulation for ini-tiation of VT was performed with ≤3 extrastimuli scanned to refrac-toriness or a minimum coupling interval of 180 ms, applied after a basic drive of 600 ms and then 400 ms from 2 right ventricular sites and burst pacing. If VT was exercise-related and usually in arrhyth-mogenic right ventricular cardiomyopathy, programmed stimulation was repeated during intravenous infusion of isoproterenol.
Mapping and ablation was performed using a 3.5-mm-tip open-ir-rigated catheter (NaviStar ThermoCool; Biosense Webster, Diamond Bat, CA) or with a 4-mm-tip nonirrigated catheter (NaviStar, Biosense Webster). Electroanatomic mapping was performed with the CARTO mapping system (CARTO 3 or XP; Biosense Webster). In the electro-anatomic mapping system, bipolar electrograms were high pass–filtered at 20 to 30 Hz and low pass–filtered at 400 Hz. Bipolar electrograms were also bandpass-filtered from 30 to 500 Hz and digitally recorded along with a 12-lead surface electrocardiography using the Cardiolab EP system (General Electric Healthcare, Buckinghamshire, UK). Voltage maps were created during sinus rhythm. Peak-to-peak bipolar electrogram amplitude <0.5 mV was defined as dense scar and volt-age ≥0.5 and <1.5 mV as scar border zone.9
Ablation targeted all inducible sustained monomorphic VTs, ini-tially focusing on clinical VTs or presumptive clinical VTs (if 12-lead electrocardiographies were not available) and including slower VTs. Remaining VTs with shorter cycle lengths than the clinical or presumptive clinical VTs were then targeted depending on whether potential substrate areas for these VTs were present and the tolerance of the patient for continuing the procedure as assessed by the treating physician. If VT was hemodynamically tolerated and reproducibly induced, mapping and ablation was performed during VT. Sites were targeted for ablation if pacing entrained the VT with concealed fusion and a postpacing interval within 30 ms of the ventricular tachycardia cycle length10,11 or in the absence of entrainment if an isolated mid-diastolic potential or presystolic potential was present. If VTs were unmappable because of hemodynamic intolerance or poor reproduc-ibility, ablation was guided by substrate mapping during sinus rhythm and limited assessment during VT, targeting presumptive channels and exits within low voltage areas identified from a paced QRS mor-phology similar to the VT QRS morphology, abnormal fractionated potentials, double potentials, or late potentials during sinus or paced rhythm at sites where pacing captured, particularly with stimulus–QRS intervals of >40 ms. If no low voltage area was identified, abla-tion was attempted at the likely exit region identified as sites with presystolic electrocardiographies during VT or where pace mapping resembled the VT QRS. Pace mapping and entrainment mapping used unipolar stimuli at 10 mA and at pulse width of 2 ms.12
Irrigated radiofrequency energy was delivered at a power of 25 to 50 watts, targeting an impedance drop of 10 to 20 ohms. At target ventricular areas (below the aortic valve), applications were usually repeated until unipolar pacing at 10 mA at 2 ms stimulus strength failed to capture.12 At target areas in the sinuses of Valsalva, power exceeding 35 watts was avoided.
Epicardial mapping was considered if a subepicardial VT origin was suspected based on endocardial mapping either at the same or at a subsequent session. Percutaneous subxiphoid epicardial access was ob-tained as previously described either before administration of systemic anticoagulation or after anticoagulation was reversed to achieve an ac-tivated clotting time of <200 s before attempting pericardial access.13
At the end of the procedure, the same stimulation protocol was repeated with or without isoproterenol infusion. Acute complete suc-cess was defined as the absence of any inducible monomorphic VT. Partial success was defined as abolition of the clinical or presump-tive clinical VT, but other VTs remained inducible; these patients were further divided into those with VTs that were faster than clini-cal VTs (fast VTs inducible) and those with VTs that were still as slow or slower than a clinical VT (slow VT inducible). Acute abla-tion failure was defined as inability to render a clinical or presumed clinical VT noninducible.
Data Collection and Follow-UpData were collected from a centralized system containing records of all patients treated and followed at Brigham and Women’s Hospital and all associated Partners Healthcare sites. These records include emergency department visits, outpatient clinic visits, data recorded during inpatient care, as well as follow-up progress notes from refer-ring physicians monitoring out-of-area patients. In addition, referring cardiologists and primary care physicians were contacted for clinical follow-up of their patients if necessary. Early recurrence was defined as spontaneous sustained VT within 7 days of ablation. Mortality was determined by interrogation of the Social Security Death Index.
Statistical AnalysisContinuous variables were expressed as mean±SD values or median, and interquartile ranges are shown in parentheses, as appropriate. Student’s t test or Mann–Whitney’s U test was used to compare continuous variables, depending on whether the values were normally distributed, and the χ2 test was used to compare dichotomous variables unless the expected values in any cells were <5, in which case Fisher exact test was used. Multivariable analysis was performed with the use of logistic regression analysis to as-sess correlates of early recurrence of VT. The following variables with P<0.05 for the comparison between early recurrence group and no early recurrence group were entered into a multivariable model: New York Heart Association (NYHA) ≥III, dilated cardiomyopathy, VT storm defined as ≥3 episodes of VT within 24 hours, oral amiodarone therapy before the hospitalization, left ventricular ejection fraction, eGFR, the number of VT morphologies induced during the procedure, and acute failure or no final induction test at the end of the procedure. The survival curves were cre-ated using the Kaplan–Meier method, and comparisons between groups are based on the log-rank test. Cox proportional hazard models were used to assess correlates of all-cause mortality. The following 10 variables that have been previously associated with outcomes8,14 were included in the unadjusted model; NYHA ≥III, ischemic cardiomyopathy, left ventricu-lar ejection fraction, eGFR, the number of failed antiarrhythmic drugs (AADs), VT storm, the number of VT morphologies induced during the procedure, acute failure of the procedure and early VT recurrence, and variables with P<0.05 were entered the multivariable Cox hazard model. P<0.05 was considered to be statistically significant. All statistical analyses were performed with JMP 9 software (SAS Institute, Cary, NC).
ResultsBaseline CharacteristicsOf the 370 patients, 58% had ischemic cardiomyopathy, and the remainder had nonischemic causes of heart disease (Table 1). During the 7 days after ablation, sustained VT recurred in 81 patients (22%), and 289 (78%) patients were free of recurrence. Over half (54%) of early recurrences were within 48 hours of the procedure (Figure 1).
The early recurrence group had more evidence of advanced cardiac failure compared with the no recurrence group by NYHA classification, lower left ventricular ejection frac-tion, and eGFR (Table 1). Dilated cardiomyopathy was more frequent in the early recurrence group. More patients in the early recurrence group had a history of VT storm and ICDs. However, there were not statistically significant differences in age, sex, body mass index, the prevalence of hypertension, hyperlipidemia, or diabetes mellitus, history of prior ablation, and ventricular assist device implantation between the 2 groups.
Electrophysiological Study and AblationEarly recurrence patients had more VT morphologies induced during the procedure; however, other VT characteristics, including the CL and hemodynamic tolerance of inducible
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Nagashima et al Correlates and Prognosis of Early VT Recurrence 885
VTs, were not different (Table 2). The early recurrence group had longer total radiofrequency application times.
Epicardial ablation tended to be used more frequently in the early recurrence group. Acute complete success was obtained less frequently, and the incidence of acute failure or no induction test after ablation was more frequent in the early recurrence group compared with the no recurrence group. The procedure was terminated because of a complication in 4 patients who had early recurrences and in 7 patients who did not have an early recurrence (P=0.27): cardiac tamponade in 3 patients with early recurrences and in 6 patients without early recurrence, coronary artery occlusion treated with emergent angioplasty in 1 patient with early recurrences, and thrombus formation in the ventricle observed on intracardiac ultrasound without embolization in 1 patient without early recurrence.
Antiarrhythmic Drug TherapyAAD therapy before hospitalization with amiodarone (65 ver-sus 47%; P=0.004) and mexiletine (31 versus 18%; P=0.01) were more common in the early recurrence group (Table I in the Data Supplement). The patients were hospitalized or transferred to our institute for a median of 2 (1, 4) days before the ablation procedure in the recurrence group and 2 (1, 3) days in the no recurrence group (P=0.71). During hospitalization before the procedure, intravenous lidocaine was required more frequently to suppress VT (52 versus 28%; P<0.0001) in the early recur-rence group, but there was no difference in administration of intravenous amiodarone between 2 groups. After the procedure, more patients resumed oral amiodarone in the early recur-rence group than in the no recurrence group (57 versus 43%; P=0.03). Immediately after the procedure, a lidocaine infusion was administered more frequently in the early recurrence group either because of recurrence or in the hope of reducing the chance of an early recurrence at the treating physicians discre-tion (14 versus 3%; P=0.0009). However, there were no differ-ences in the administration of sotalol or other β-blocker.
Correlates of Early VT RecurrenceMultivariable logistic analysis revealed that NYHA clas-sification ≥III (odds ratio [OR] 1.90, 95% CI 1.03–3.48; P=0.04), dilated cardiomyopathy (OR 1.93, 95% CI 1.03–3.57; P=0.04), prevalence of VT storm before the procedure (OR 2.62, 95% CI 1.48–4.65; P=0.001), a greater number of induced VTs (OR 1.24, 95% CI 1.07–1.45; P=0.006), and the acute failure or no final induction test (OR 1.88, 95% CI 1.03–3.40; P=0.04) were independently associated with early VT recurrence (Table II in the Data Supplement).
Follow-Up and MortalityIn 58 of 81 early recurrence patients, the morphology of the VT that recurred was available, and VT morphology was simi-lar to the clinical VT morphologies noted before ablation in 27 patients (47%).
A flow chart indicating follow-up details in early recurrence patients is shown in Figure 2. In the early recurrence group, 44 of 81 (54%) patients underwent repeat ablation during the same hospitalization, and acute complete success was achieved in
Table 1. Patient Characteristics With and Without Early Recurrence of VT
Early Recurrence of VT
P ValueYes (n=81) No (n=289)
Age, y 63.5±12.0 62.8±13.5 0.67
Men 68 (84) 245 (85) 0.86
Body mass index, kg/m2 29.5±5.8 28.1±5.8 0.06
Hypertension 40 (49) 173 (60) 0.09
Hyperlipidemia 55 (68) 193 (67) 0.85
Diabetes mellitus 18 (22) 72 (25) 0.62
Pathogenesis
Ischemic heart disease 42 (52) 174 (60) 0.18
Nonischemic cardiomyopathy 40 (49) 120 (42)
DCM 28 (35) 53 (18) 0.002
ARVC 2 (2) 16 (6)
Cardiac sarcoidosis 5 (6) 8 (3)
HCM 1 (1) 4 (1)
Valvular heart disease 3 (4) 12 (4)
Congenital heart disease 0 (0) 10 (3)
Myocarditis 0 (0) 3 (1)
Restrictive cardiomyopathy 0 (0) 1 (0.4)
Idiopathic aneurysm 0 (0) 1 (0.4)
Unspecified cardiomyopathy by MRI or voltage map
1 (1) 8 (3)
NYHA ≥III 40 (49) 68 (24) <0.0001
History of prior ablation 27 (33) 96 (33) 0.98
VT storm 44 (54) 73 (25) <0.0001
Device
ICD 78 (96) 258 (89) 0.05
CRT 31 (38) 85 (29) 0.13
VAD 1 (1.2) 2 (0.7) 0.52
LVEF, % 28.0±10.8 34.7±14.3 <0.0001
eGFR, mL/min/1.73 m2 60.0±22.7 68.4±25.3 0.006
Values are the mean±SD or n (%).ARVC indicates arrhythmogenic right ventricular cardiomyopathy; CRT,
cardiac resynchronization therapy; DCM, dilated cardiomyopathy; eGFR, estimate glomerular filtration rate; HCM, hypertrophic cardiomyopathy; ICD, implantable cardioverter defibrillator; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; VAD, ventricular assist device; and VT, ventricular tachycardia.
17 of 44 (39%) patients. However, 26 of the 44 (59%) patients had further VT recurrence that occurred at a median of 26 (2, 121) days of follow-up, and 13 (30%) patients underwent >3 ablation procedures. The 37 of 81 (46%) patients discharged without repeat ablation were managed with increased AAD in 19 patients, increased β-blocker in 7 patients, no medica-tion change in 8 patients; and 3 patients died. However, 14 of these 37 (38%) patients subsequently had another ablation procedure because of further VT recurrences, despite of medi-cation. Although acute complete success was acquired in 5 of 14 (36%) patients, 8 (57%) patients had further VT recurrence at a median of 103 (7, 432) follow-up days.
Kaplan–Meier curves of all-cause mortality are shown in Figure 3A and 3B. During a median of 2.5 (1.2, 4.0) years of follow-up, the mortality was significantly greater in the early recurrence group (P<0.0001 by log-rank test; Figure 3A). The 1-year mortality for the early recurrence group was 32%, despite of 9% for no early recurrence group. Within the early recurrence group, the difference in the mortality between the 44 patients who underwent repeat ablation during that hos-pitalization and patients without early repeat ablation did not reach statistical significance (P=0.85 by log-rank test; Figure 3B). In Cox, univariable analysis revealed that higher age, NYHA ≥III, lower left ventricular ejection fraction and
eGFR, a history of VT storm, the number of VT morpholo-gies induced during the procedure, acute ablation failure, and early VT recurrence associated with mortality. After adjust-ment for these variables, early VT recurrence remained an independent correlate of mortality (hazard ratio 2.59, 95% CI 1.52–4.34; P=0.0005; Table III in the Data Supplement).
DiscussionCatheter ablation of VT because of heart disease is often chal-lenging. Recurrence rates and mortality during long-term follow-up remain significant, and recurrences have been associ-ated with increased mortality.3 We found that 20% of patients have early (within 7 days) recurrent VT, most within 48 hours, and these early recurrences were associated with a 2.6-fold increased risk for mortality during longer-term follow-up. The timing and prognostic significance of recurrences has important implications for patient management, including timing of hos-pital discharge, consideration of repeat ablation procedures, and therapy adjustments, and potentially long-term management strategies. Furthermore, retrospective analysis identified factors associated with increased risk for early recurrence that might be used to individualize the post ablation management.
There are several potential contributors to early recurrences of VT. The VT substrate may not be adequately ablated, per-haps because of anatomic obstacles, and the same VT remains inducible and subsequently recurs. The majority (58%) of patients who had early recurrences either still had an induc-ible VT after ablation or complete programmed stimulation was not performed at the end of the procedure. However, the majority (71% of the 159 patients) who had an inducible VT or no induction test after ablation did not have an early recur-rence. These findings are consistent with the observations of others that programmed stimulation has somewhat limited ability to predict outcome.6
We also observed, however, that 43% of patients who had an early recurrence did not have any VT inducible at the end of the ablation procedure. Of the 211 patients who had no inducible VT at the end of the procedure, 35 (17%) had an early VT recur-rence. There is increasing evidence, from others, that this finding is a favorable marker of outcome.15,16 When VT is not inducible at the end of the procedure VT recurrence may indicate healing of ablation lesions. In our series, the morphology of recurrent VT was available in 38 patients in whom at least clinical VT was not inducible at the end of the procedure and was similar to the clinical VT in 19 patients (50%). In some patients, a decrease in AAD effects after ablation because of drug withdrawal or reduc-tion may lead to occurrence of a previously suppressed VT. In 32 of 81 patients (40%) with early VT recurrence, AADs were reduced in dose or withdrawn after the procedure, although there was no difference between the patients with and without the early recurrence (40% versus 46%; P=0.32). A proarrhyth-mic effect of ablation, with emergence of new reentry circuits as ablation lesions heal, is also theoretically possible.
Early VT recurrences were an independent correlate for mortality, despite the presence of an ICD. Whether mortal-ity is directly related to further VT recurrences is not clear. Recurrent VT may be slow and below the detect rate of the ICD, perhaps contributing to aggravation of heart failure. VT storm may lead to death, despite an ICD. In this study, 45
Table 2. Procedure Details in Patients With and Without Early Recurrence of VT
Early Recurrence of VT
P ValueYes (n=81) No (n=289)
VT characteristics
No. of VT morphologies induced 3.5±1.9 2.6±1.7 <0.0001
Only nonsustained arrhythmia inducible 2 (2.5) 12 (4.2) 0.74
Any VTCL >400 ms 48 (59) 155 (54) 0.38
Any VTCL <400 ms 66 (81) 218 (75) 0.25
Only mappable VT 18 (22) 64 (22) 0.99
Only unmappable VT 31 (38) 129 (45) 0.31
Ablation strategy
Irrigated catheter 78 (96) 282 (98) 0.53
Endocardial ablation 75 (93) 272 (94) 0.62
LV ablation 70 (86) 227 (79) 0.12
RV ablation 27 (33) 87 (30) 0.58
Epicardial ablation 19 (23) 42 (15) 0.06
Radiofrequency time, min 38.1±23.7 31.6±22.1 0.03
Ablation outcome
Acute complete success 35 (43) 176 (61) 0.005
Partial success 14 (17) 46 (16) 0.77
Fast VTs inducible 7/14 (50) 31/46 (68) 0.24
Slow VT inducible 7/14 (50) 15/46 (33) 0.24
Elimination of clinical and slower VTs 42 (52) 207 (72) 0.0008
Acute failure or no final induction test 32 (40) 67 (23) 0.003
Procedure terminated because of complication
4 (4.9) 7 (2.4) 0.27
Values are the mean±SD or n (%).CL indicates cycle length; LV, left ventricle; RV, right ventricle; and VT,
ventricular tachycardia.
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Nagashima et al Correlates and Prognosis of Early VT Recurrence 887
patients (56%) had early VT recurrence with VT storms. These considerations raise the possibility that further early ablation to attempt to reduce recurrences may improve outcomes. Our patients who had early recurrence treated with repeat ablation during the same hospitalization did not have a statistically better outcome than those who did not have a repeat abla-tion (Figure 3B). However, the approach to early recurrence was not randomized. Patients selected to have repeat ablation were likely sicker and more had VT storm (68 versus 41%; P=0.01). Further study is needed to determine whether more extensive ablation and attempts to achieve complete abolition of inducible VT will improve outcomes.17–19
LimitationsAlthough the VT ablation data are collected prospectively, this study was retrospective. Whether the factors associated with early recurrences are adequate correlates requires prospective validation. The definition of early recurrence as within 7 days was selected arbitrarily. The majority of recurrences within the
first 30 days were within 48 hours, and there remains a relation to mortality regardless of whether the definition of early recur-rence is <3, 10, or 30 days (data not shown). Several biases undoubtedly determine who is referred for VT ablation. In the present study, isolated VT recurrences that did not result in hos-pitalization and were not detected by referring cardiologists or primary care physicians were not included as an end point dur-ing follow-up. Detection of these events in our referral popula-tion can be problematic, and isolated VT recurrences may not preclude good long-term control and clinical benefit.
Clinical ImplicationsVT recurs within 7 days in 22% of patients who are undergo-ing catheter ablation for VT associated with structural heart disease and is more likely in those with worse NYHA clas-sification, dilated cardiomyopathy, a history of VT storm, a greater number of induced VT morphologies during the pro-cedure, and the acute failure or no final induction test. An early recurrence is associated with a greater mortality during
VT ablationn=370
Recurrence within 7 daysn=81
No recurrence within 7 daysn=289
Early repeat ablation during the same hospitalization
n=44
No early repeat ablation during the same hospitalization
Figure 2. A flow chart indicating follow-up details in patients with early recurrence of ventricular tachycardia. AADs indicates antiarrhythmic durgs; and VT, ventricular tachycardia.
Time (year)
Cum
ulat
ive
surv
ival
(%)
0 1 2 3 4 5
80
60
40
20
0
100AP<0.0001
No. at risk
No early recurrence
Early recurrence
289 258 171 126 77 24
81 56 40 28 18 4
Time (year)
Cum
ulat
ive
surv
ival
(%)
0 1 2 3 4 5
80
60
40
20
0
100
No. at risk
Early repeat ablation
No early repeat ablation
44 32 25 17 11 2
36 25 16 12 7 2
P=0.85 forEarly repeat ablation vs. No early repeat ablation
No early recurrence 289 258 171 126 77 24
B
Early recurrenceNo early recurrence No early recurrence
Early repeat ablationNo early repeat ablation
Figure 3. A, Kaplan–Meier curves showing all cause mortality in the patients with and without the early recurrence of ventricular tachy-cardia; P<0.001 for patients with vs without early recurrence. B, Kaplan–Meier curves showing all cause mortality among 3 groups, including the patients who underwent the repeat ablation during the same hospitalization and the patients without repeat ablation for the early recurrence and the patients without the early recurrence; P=0.85 for patients with early repeat ablation vs patients without early repeat ablation.
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follow-up. Whether patients with these risk factors might ben-efit from longer hospital monitoring and reassessment of drug therapy and possible early repeat ablation or more extensive ablation warrants further investigation.
Sources of FundingDr Nagashima was supported in part by a Medtronic Japan Fellowship.
DisclosuresWilliam Stevenson is co-holder of a patent for needle ablation that is consigned to Brigham and Women’s Hospital.
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CLINICAL PERSPECTIVERecurrent ventricular tachycardia (VT) after catheter ablation in patients with structural heart disease is common. This study assessed the prognostic significance of the timing of recurrent VT to help define the appropriate duration for in-hospital monitoring and suggest management strategies. VT recurred early (within 7 days) in 22% of patients, most within 48 hours. Early recurrence was associated with worse New York Heart Association class, a history of VT storm, the number of induced VTs, and acute procedure outcome. Early VT recurrence was associated with a 2.6-fold increased risk for mortality during follow-up. Thus, patients who have early recurrences are a high risk group who may be identifiable from their clinical profile, suggesting a group of patients who should be monitored for ≥48 hours after ablation and considered for additional therapy or management strategies if VT recurs early.
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William G. StevensonY. Lin, Chirag R. Barbhaiya, Jason S. Chinitz, Alan D. Enriquez, Alan F. Helmbold and
Roy M. John, Laurence M. Epstein, Michifumi Tokuda, Keiichi Inada, Saurabh Kumar, Kaity Koichi Nagashima, Eue-Keun Choi, Usha B. Tedrow, Bruce A. Koplan, Gregory F. Michaud,
Tachycardia due to Structural Heart DiseaseCorrelates and Prognosis of Early Recurrence After Catheter Ablation for Ventricular
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