Electrophysiologic Substrate, Safety, Procedural Approaches, and Outcomes of Catheter Ablation for Ventricular Tachycardia in Patients After Aortic Valve Replacement

Jackson J. Liang, Simon A. Castro, Daniele Muser, David F. Briceno, Yasuhiro Shirai, Andres Enriquez, Ramanan Kumareswaran, Pasquale Santangeli, Erica S. Zado, Jeffrey S. Arkles, Robert D. Schaller, Gregory E. Supple, David S. Frankel, Saman Nazarian, Michael P. Riley, Fermin C. Garcia, David Lin, Sanjay Dixit, David J. Callans, Francis E. Marchlinski

Research output: Contribution to journalArticlepeer-review

4 Scopus citations

Abstract

Objectives: This study sought to investigate the substrate, procedural strategies, safety, and outcomes of catheter ablation (CA) for ventricular tachycardia (VT) in patients with aortic valve replacement (AVR). Background: VT ablation in patients with AVR is challenging, particularly when mapping and ablation in the periaortic region are necessary. Methods: We identified consecutive patients with mechanical, bioprosthetic, and transcatheter AVR who underwent CA for VT refractory to antiarrhythmic drugs and analyzed VT substrate, approach to LV access, complications, and long-term outcomes. Results: Overall, 29 patients (87% men, mean age 67.9 ± 9.8 years, left ventricular ejection fraction 39 ± 10%) with prior AVR (13 mechanical, 15 bioprosthetic, 1 transcatheter AVR) underwent 40 ablations from 2004 to 2016. Left-sided mapping/CA was performed in 27 patients (36 procedures). Access was retrograde aortic in 11 procedures (all bioprosthetic), transseptal in 24 (13 mechanical; 10 bioprosthetic; 1 transcatheter AVR), or transventricular septal in 1. Periaortic bipolar or unipolar scar was detected in all 24 patients in whom detailed periaortic mapping was performed. Clinical VT circuit(s) involved the periaortic region in 10 patients (34%), 2 (7%) had bundle branch re-entry VT, and 17 (59%) had substrate unrelated to AVR. There were 2 major complications (both related to vascular access). Only 2 patients (9.1%) had VT recurrence. Over median follow-up of 12.8 months, 11 patients died (none as a result of recurrent VT). Conclusions: Whereas most patients undergoing CA for VT after AVR had VT from substrate unrelated to AVR, periaortic scar is universally present and bundle branch re-entry can be the VT mechanism. CA can be safely performed with excellent long-term VT elimination.

Original languageEnglish (US)
Pages (from-to)28-38
Number of pages11
JournalJACC: Clinical Electrophysiology
Volume5
Issue number1
DOIs
StatePublished - Jan 2019
Externally publishedYes

Keywords

  • aortic valve replacement
  • cardiomyopathy
  • catheter ablation
  • safety
  • ventricular tachycardia

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

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