Proactive Mapping and Preventive Ablation Reduce Defibrillator Implantation Rates in Tetralogy of Fallot
In patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by ablation results in excellent long-term VT-free survival. In patients without prior VT, proactive electroanatomical mapping and preventive SC...
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| Published in | Journal of the American College of Cardiology Vol. 85; no. 17; pp. 1695 - 1705 |
|---|---|
| Main Authors | , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
United States
Elsevier Inc
06.05.2025
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| Subjects | |
| Online Access | Get full text |
| ISSN | 0735-1097 1558-3597 1558-3597 |
| DOI | 10.1016/j.jacc.2025.03.523 |
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| Abstract | In patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by ablation results in excellent long-term VT-free survival. In patients without prior VT, proactive electroanatomical mapping and preventive SCAI ablation may impact patient selection for primary prevention implantable cardioverter-defibrillator (ICD) implantation.
The purpose of this study was to evaluate long-term outcomes after proactive electroanatomical mapping and ablation of SCAI and its impact on patient selection for primary prevention ICD implantation, compared with current risk stratification methods in rTOF patients without prior VT.
Consecutive rTOF patients without prior VT who underwent electroanatomical mapping for VT substrate identification were included (2005-2020). After successful SCAI ablation, ICD implantation was offered but was subject to shared decision making. The potential eligibility for ICD implantation was retrospectively determined using the following: 1) a clinical risk score; 2) guideline-recommended risk factors (American Heart Association [AHA] 2018 guidelines without late gadolinium enhancement [LGE] on cardiac magnetic resonance [CMR] information, AHA 2018 guidelines with LGE-CMR information, European Society of Cardiology [ESC] 2022 guidelines); and 3) electroanatomical mapping and SCAI ablation results. In the latter, patients with a nontransected SCAI, VT substrates remote from anatomical isthmuses, or severe right-/left ventricular dysfunction qualified for ICDs.
A total of 97 patients were included (age 35 ± 16 years, 57 men); 33 patients (34%) had SCAI and 19 (20%) had inducible monomorphic VT (17 of 19 SCAI-dependent VT). Successful SCAI transection was achieved in 87% (26 of 30 patients) in whom attempted, without complications. In total, 13 patients received an ICD implantation. During a median follow-up of 58 months (Q1-Q3: 30-99 months), 4 patients (4%) had VT, all after ablation failure. According to clinical risk score, AHA 2018 guidelines without LGE-CMR information, AHA 2018 guidelines with LGE-CMR information, and ESC 2022 guidelines, 49 (51%), 24 (25%), 31 (32%), and 48 patients (49%) would have qualified for ICDs, respectively. After proactive mapping and preventive ablation, 11 patients (11%) remained ICD candidates, including all 4 with a VT event during the follow-up (annual VT risk 7%/y).
Long-term outcome of rTOF patients without SCAI is excellent. Proactive electroanatomical mapping and preventive SCAI ablation may significantly reduce primary prevention ICD implantation rates compared with current risk prediction methods.
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| AbstractList | In patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by ablation results in excellent long-term VT-free survival. In patients without prior VT, proactive electroanatomical mapping and preventive SCAI ablation may impact patient selection for primary prevention implantable cardioverter-defibrillator (ICD) implantation.BACKGROUNDIn patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by ablation results in excellent long-term VT-free survival. In patients without prior VT, proactive electroanatomical mapping and preventive SCAI ablation may impact patient selection for primary prevention implantable cardioverter-defibrillator (ICD) implantation.The purpose of this study was to evaluate long-term outcomes after proactive electroanatomical mapping and ablation of SCAI and its impact on patient selection for primary prevention ICD implantation, compared with current risk stratification methods in rTOF patients without prior VT.OBJECTIVESThe purpose of this study was to evaluate long-term outcomes after proactive electroanatomical mapping and ablation of SCAI and its impact on patient selection for primary prevention ICD implantation, compared with current risk stratification methods in rTOF patients without prior VT.Consecutive rTOF patients without prior VT who underwent electroanatomical mapping for VT substrate identification were included (2005-2020). After successful SCAI ablation, ICD implantation was offered but was subject to shared decision making. The potential eligibility for ICD implantation was retrospectively determined using the following: 1) a clinical risk score; 2) guideline-recommended risk factors (American Heart Association [AHA] 2018 guidelines without late gadolinium enhancement [LGE] on cardiac magnetic resonance [CMR] information, AHA 2018 guidelines with LGE-CMR information, European Society of Cardiology [ESC] 2022 guidelines); and 3) electroanatomical mapping and SCAI ablation results. In the latter, patients with a nontransected SCAI, VT substrates remote from anatomical isthmuses, or severe right-/left ventricular dysfunction qualified for ICDs.METHODSConsecutive rTOF patients without prior VT who underwent electroanatomical mapping for VT substrate identification were included (2005-2020). After successful SCAI ablation, ICD implantation was offered but was subject to shared decision making. The potential eligibility for ICD implantation was retrospectively determined using the following: 1) a clinical risk score; 2) guideline-recommended risk factors (American Heart Association [AHA] 2018 guidelines without late gadolinium enhancement [LGE] on cardiac magnetic resonance [CMR] information, AHA 2018 guidelines with LGE-CMR information, European Society of Cardiology [ESC] 2022 guidelines); and 3) electroanatomical mapping and SCAI ablation results. In the latter, patients with a nontransected SCAI, VT substrates remote from anatomical isthmuses, or severe right-/left ventricular dysfunction qualified for ICDs.A total of 97 patients were included (age 35 ± 16 years, 57 men); 33 patients (34%) had SCAI and 19 (20%) had inducible monomorphic VT (17 of 19 SCAI-dependent VT). Successful SCAI transection was achieved in 87% (26 of 30 patients) in whom attempted, without complications. In total, 13 patients received an ICD implantation. During a median follow-up of 58 months (Q1-Q3: 30-99 months), 4 patients (4%) had VT, all after ablation failure. According to clinical risk score, AHA 2018 guidelines without LGE-CMR information, AHA 2018 guidelines with LGE-CMR information, and ESC 2022 guidelines, 49 (51%), 24 (25%), 31 (32%), and 48 patients (49%) would have qualified for ICDs, respectively. After proactive mapping and preventive ablation, 11 patients (11%) remained ICD candidates, including all 4 with a VT event during the follow-up (annual VT risk 7%/y).RESULTSA total of 97 patients were included (age 35 ± 16 years, 57 men); 33 patients (34%) had SCAI and 19 (20%) had inducible monomorphic VT (17 of 19 SCAI-dependent VT). Successful SCAI transection was achieved in 87% (26 of 30 patients) in whom attempted, without complications. In total, 13 patients received an ICD implantation. During a median follow-up of 58 months (Q1-Q3: 30-99 months), 4 patients (4%) had VT, all after ablation failure. According to clinical risk score, AHA 2018 guidelines without LGE-CMR information, AHA 2018 guidelines with LGE-CMR information, and ESC 2022 guidelines, 49 (51%), 24 (25%), 31 (32%), and 48 patients (49%) would have qualified for ICDs, respectively. After proactive mapping and preventive ablation, 11 patients (11%) remained ICD candidates, including all 4 with a VT event during the follow-up (annual VT risk 7%/y).Long-term outcome of rTOF patients without SCAI is excellent. Proactive electroanatomical mapping and preventive SCAI ablation may significantly reduce primary prevention ICD implantation rates compared with current risk prediction methods.CONCLUSIONSLong-term outcome of rTOF patients without SCAI is excellent. Proactive electroanatomical mapping and preventive SCAI ablation may significantly reduce primary prevention ICD implantation rates compared with current risk prediction methods. AbstractBackgroundIn patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by ablation results in excellent long-term VT-free survival. In patients without prior VT, proactive electroanatomical mapping and preventive SCAI ablation may impact patient selection for primary prevention implantable cardioverter-defibrillator (ICD) implantation. ObjectivesThe purpose of this study was to evaluate long-term outcomes after proactive electroanatomical mapping and ablation of SCAI and its impact on patient selection for primary prevention ICD implantation, compared with current risk stratification methods in rTOF patients without prior VT. MethodsConsecutive rTOF patients without prior VT who underwent electroanatomical mapping for VT substrate identification were included (2005-2020). After successful SCAI ablation, ICD implantation was offered but was subject to shared decision making. The potential eligibility for ICD implantation was retrospectively determined using the following: 1) a clinical risk score; 2) guideline-recommended risk factors (American Heart Association [AHA] 2018 guidelines without late gadolinium enhancement [LGE] on cardiac magnetic resonance [CMR] information, AHA 2018 guidelines with LGE-CMR information, European Society of Cardiology [ESC] 2022 guidelines); and 3) electroanatomical mapping and SCAI ablation results. In the latter, patients with a nontransected SCAI, VT substrates remote from anatomical isthmuses, or severe right-/left ventricular dysfunction qualified for ICDs. ResultsA total of 97 patients were included (age 35 ± 16 years, 57 men); 33 patients (34%) had SCAI and 19 (20%) had inducible monomorphic VT (17 of 19 SCAI-dependent VT). Successful SCAI transection was achieved in 87% (26 of 30 patients) in whom attempted, without complications. In total, 13 patients received an ICD implantation. During a median follow-up of 58 months (Q1-Q3: 30-99 months), 4 patients (4%) had VT, all after ablation failure. According to clinical risk score, AHA 2018 guidelines without LGE-CMR information, AHA 2018 guidelines with LGE-CMR information, and ESC 2022 guidelines, 49 (51%), 24 (25%), 31 (32%), and 48 patients (49%) would have qualified for ICDs, respectively. After proactive mapping and preventive ablation, 11 patients (11%) remained ICD candidates, including all 4 with a VT event during the follow-up (annual VT risk 7%/y). ConclusionsLong-term outcome of rTOF patients without SCAI is excellent. Proactive electroanatomical mapping and preventive SCAI ablation may significantly reduce primary prevention ICD implantation rates compared with current risk prediction methods. In patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by ablation results in excellent long-term VT-free survival. In patients without prior VT, proactive electroanatomical mapping and preventive SCAI ablation may impact patient selection for primary prevention implantable cardioverter-defibrillator (ICD) implantation. The purpose of this study was to evaluate long-term outcomes after proactive electroanatomical mapping and ablation of SCAI and its impact on patient selection for primary prevention ICD implantation, compared with current risk stratification methods in rTOF patients without prior VT. Consecutive rTOF patients without prior VT who underwent electroanatomical mapping for VT substrate identification were included (2005-2020). After successful SCAI ablation, ICD implantation was offered but was subject to shared decision making. The potential eligibility for ICD implantation was retrospectively determined using the following: 1) a clinical risk score; 2) guideline-recommended risk factors (American Heart Association [AHA] 2018 guidelines without late gadolinium enhancement [LGE] on cardiac magnetic resonance [CMR] information, AHA 2018 guidelines with LGE-CMR information, European Society of Cardiology [ESC] 2022 guidelines); and 3) electroanatomical mapping and SCAI ablation results. In the latter, patients with a nontransected SCAI, VT substrates remote from anatomical isthmuses, or severe right-/left ventricular dysfunction qualified for ICDs. A total of 97 patients were included (age 35 ± 16 years, 57 men); 33 patients (34%) had SCAI and 19 (20%) had inducible monomorphic VT (17 of 19 SCAI-dependent VT). Successful SCAI transection was achieved in 87% (26 of 30 patients) in whom attempted, without complications. In total, 13 patients received an ICD implantation. During a median follow-up of 58 months (Q1-Q3: 30-99 months), 4 patients (4%) had VT, all after ablation failure. According to clinical risk score, AHA 2018 guidelines without LGE-CMR information, AHA 2018 guidelines with LGE-CMR information, and ESC 2022 guidelines, 49 (51%), 24 (25%), 31 (32%), and 48 patients (49%) would have qualified for ICDs, respectively. After proactive mapping and preventive ablation, 11 patients (11%) remained ICD candidates, including all 4 with a VT event during the follow-up (annual VT risk 7%/y). Long-term outcome of rTOF patients without SCAI is excellent. Proactive electroanatomical mapping and preventive SCAI ablation may significantly reduce primary prevention ICD implantation rates compared with current risk prediction methods. [Display omitted] In patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by ablation results in excellent long-term VT-free survival. In patients without prior VT, proactive electroanatomical mapping and preventive SCAI ablation may impact patient selection for primary prevention implantable cardioverter-defibrillator (ICD) implantation. The purpose of this study was to evaluate long-term outcomes after proactive electroanatomical mapping and ablation of SCAI and its impact on patient selection for primary prevention ICD implantation, compared with current risk stratification methods in rTOF patients without prior VT. Consecutive rTOF patients without prior VT who underwent electroanatomical mapping for VT substrate identification were included (2005-2020). After successful SCAI ablation, ICD implantation was offered but was subject to shared decision making. The potential eligibility for ICD implantation was retrospectively determined using the following: 1) a clinical risk score; 2) guideline-recommended risk factors (American Heart Association [AHA] 2018 guidelines without late gadolinium enhancement [LGE] on cardiac magnetic resonance [CMR] information, AHA 2018 guidelines with LGE-CMR information, European Society of Cardiology [ESC] 2022 guidelines); and 3) electroanatomical mapping and SCAI ablation results. In the latter, patients with a nontransected SCAI, VT substrates remote from anatomical isthmuses, or severe right-/left ventricular dysfunction qualified for ICDs. A total of 97 patients were included (age 35 ± 16 years, 57 men); 33 patients (34%) had SCAI and 19 (20%) had inducible monomorphic VT (17 of 19 SCAI-dependent VT). Successful SCAI transection was achieved in 87% (26 of 30 patients) in whom attempted, without complications. In total, 13 patients received an ICD implantation. During a median follow-up of 58 months (Q1-Q3: 30-99 months), 4 patients (4%) had VT, all after ablation failure. According to clinical risk score, AHA 2018 guidelines without LGE-CMR information, AHA 2018 guidelines with LGE-CMR information, and ESC 2022 guidelines, 49 (51%), 24 (25%), 31 (32%), and 48 patients (49%) would have qualified for ICDs, respectively. After proactive mapping and preventive ablation, 11 patients (11%) remained ICD candidates, including all 4 with a VT event during the follow-up (annual VT risk 7%/y). Long-term outcome of rTOF patients without SCAI is excellent. Proactive electroanatomical mapping and preventive SCAI ablation may significantly reduce primary prevention ICD implantation rates compared with current risk prediction methods. |
| Author | Bokma, Jouke P. Brouwer, Charlotte Blom, Nico A. Wallet, Justin Bertels, Robin A. Jongbloed, Monique R.M. Zeppenfeld, Katja Kimura, Yoshitaka Hazekamp, Mark G. |
| Author_xml | – sequence: 1 givenname: Yoshitaka orcidid: 0000-0002-0422-7515 surname: Kimura fullname: Kimura, Yoshitaka organization: Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands – sequence: 2 givenname: Justin orcidid: 0000-0002-0868-7068 surname: Wallet fullname: Wallet, Justin organization: Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands – sequence: 3 givenname: Charlotte surname: Brouwer fullname: Brouwer, Charlotte organization: Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands – sequence: 4 givenname: Jouke P. orcidid: 0000-0002-8808-4573 surname: Bokma fullname: Bokma, Jouke P. organization: Department of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands – sequence: 5 givenname: Robin A. orcidid: 0000-0002-9179-7953 surname: Bertels fullname: Bertels, Robin A. organization: Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, the Netherlands – sequence: 6 givenname: Monique R.M. orcidid: 0000-0002-9132-0418 surname: Jongbloed fullname: Jongbloed, Monique R.M. organization: Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands – sequence: 7 givenname: Mark G. surname: Hazekamp fullname: Hazekamp, Mark G. organization: Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, the Netherlands – sequence: 8 givenname: Nico A. surname: Blom fullname: Blom, Nico A. organization: Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, the Netherlands – sequence: 9 givenname: Katja surname: Zeppenfeld fullname: Zeppenfeld, Katja email: k.zeppenfeld@lumc.nl organization: Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/40306842$$D View this record in MEDLINE/PubMed |
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| Keywords | AI catheter ablation ICD LGE tetralogy of Fallot rTOF FQRS PVR EAM ventricular tachycardia congenital heart disease anatomical isthmus implantable cardioverter-defibrillator SCAI SMVT VT electroanatomical mapping pulmonary valve replacement slow-conducting anatomical isthmus fragmented QRS complex repaired tetralogy of Fallot late gadolinium enhancement sustained monomorphic ventricular tachycardia |
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| Snippet | In patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical isthmus (SCAI) by... AbstractBackgroundIn patients with repaired tetralogy of Fallot (rTOF) and spontaneous ventricular tachycardia (VT), transection of slow-conducting anatomical... |
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| SubjectTerms | Adult anatomical isthmus Cardiovascular catheter ablation Catheter Ablation - methods congenital heart disease Defibrillators, Implantable - statistics & numerical data Female Humans implantable cardioverter-defibrillator Male Middle Aged Primary Prevention - methods Retrospective Studies Tachycardia, Ventricular - etiology Tachycardia, Ventricular - prevention & control Tachycardia, Ventricular - therapy tetralogy of Fallot Tetralogy of Fallot - complications Tetralogy of Fallot - physiopathology Tetralogy of Fallot - surgery ventricular tachycardia |
| Title | Proactive Mapping and Preventive Ablation Reduce Defibrillator Implantation Rates in Tetralogy of Fallot |
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