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Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radiofrequency catheter ablation
Journal of Electrocardiology xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Journal of Electrocardiology journal homepage: www.jecgonline.com
Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radiofrequency catheter ablation☆ Dirk Prochnau, MD ⁎, Matthias Hoyme, MD Department of Cardiology, Catholic “St. Johann Nepomuk” Hospital, Erfurt, Germany
a r t i c l e
i n f o
Available online xxxx Keywords: VT ablation Renal denervation Electrical storm Outcome
a b s t r a c t Electrical storm (ES) represents a critical state of electrical instability. We describe a patient with coronary artery disease, mechanical aortic valve replacement, and reduced left ventricular function with recurrent ICD shocks. Despite medical treatment with beta-blocker and amiodarone, and after successful ablation of different VT morphologies in combination with substrate modification, ES could not be controlled. We performed renal denervation (RDN) to reduce arrhythmic burden. Thereafter, patient remained free from sustained and non-sustained VTs at 6-month follow-up. RDN is an effective second-line treatment option in patients in whom conventional catheter ablation and medical treatment failed to control the VTs. © 2018 Elsevier Inc. All rights reserved.
Introduction Electrical storm (ES) represents a critical state of electrical instability in patients with cardiac diseases. It is characterized by several episodes of ventricular tachycardias (VT) within a short time. In patients with an implantable cardioverter-defibrillator (ICD) ES is defined as three or more appropriate VT detections within 24 h. Antiarrhythmic therapy and conventional radiofrequency (RF) catheter ablation are the standard of care in patients with VT and recurrent appropriate ICD shocks [1]. However, in some cases, these therapies are not able to control the VT. The autonomic nervous system plays an important role in the genesis and maintenance of arrhythmias [2]. It has been shown that renal denervation (RDN) can modify sympathetic nerve activity [3,4] and therefore reduce arrhythmic burden, especially if conventional catheter ablation of VT failed to control the arrhythmia [5]. The case An 82-year-old patient was admitted to our hospital because of recurrent appropriate ICD shocks. The patient had known coronary heart disease and severe reduced left ventricular ejection fraction (LVEF). Because of aortic stenosis patient had bileaflet mechanical aortic valve replacement in 2003. Comorbidity included type 2 diabetes mellitus and chronic renal insufficiency. Coronary angiography showed three-vessel coronary artery disease without significant stenosis after several coronary interventions. Despite treatment with beta-blocker ☆ Declarations of interest: None. ⁎ Corresponding author at: Catholic St. Johann Nepomuk Hospital, Haarbergstrasse 72, 99097 Erfurt, Germany. E-mail address: [email protected] (D. Prochnau).
and amiodarone in adequate dosages several episodes of VT recurred. Therefore, we decided to perform left ventricular (LV) radiofrequency (RF) ablation of VT using an antegrad-transseptal approach. Electroanatomic voltage mapping of the LV (EnsitePrecision cardiac mapping system, SJM, St. Paul, MN, USA) in sinus rhythm disclosed a large posterior and inferior scar area. During electrophysiological study a monomorphic VT was induced by programmed ventricular stimulation (PVS). After entrainment with perfect match (12/12), the VT could be ablated successfully in an antero-septal position of the LV (Fig. 1A). However, repeated PVS induced two badly tolerated VTs (Fig. 2). Therefore, we performed extensive substrate modification in the border zone of the scar after cardioversion of the VTs. The patient was discharged from hospital in stable condition under antiarrhythmic treatment with amiodarone and beta-blocker. Two weeks later the patient was again admitted with ES. Antiarrhythmic treatment was changed to sotalol and later to flecainid. This treatment remained without effect and second ablation of VT was performed. We could induce and ablate another monomorphic VT arising from an infero-apical position. After a perfect entrainment manoeuvre (Fig. 1B) it was ablated successfully until non-inducibility. Patient was referred to the intermediated care station. During the next days, the patient experienced recurrent sustained and non-sustained polymorphic VTs. Three days later, we decided to make a third ablation attempt. During this procedure, VT was not inducible. After extensive substrate modification around the large inferior infarct scar area of the LV (Fig. 3A and B), we performed RDN of both renal arteries as second-line option (Fig. 3C\\F). Three days later, the patient could be discharged from hospital in a stable condition. Antiarrhythmic treatment after discharge consisted of 10 mg bisoprolol and 300 mg amiodarone daily. Since that time, the patient remained stable in a good physical condition. ICD interrogation at 6-month FU found no more sustained or non-sustained VT (ICD with programmed VT-1
https://doi.org/10.1016/j.jelectrocard.2018.01.004 0022-0736/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004
2 D. Prochnau, M. Hoyme / Journal of Electrocardiology xxx (2018) xxx–xxx
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004
Fig. 1. Surface ECG and intracardiac recordings of monomorphic ventricular tachyarrhythmia (VT). (A) VT1 with perfect match (12/12) during entrainment manoeuvre in an antero-septal position. During ablation with an irrigated radiofrequency catheter at this position, VT terminated after increase in cycle length (CL). (B) VT2 with entrainment in an infero-apical position with perfect match. Entrainment from this site showed an exact match from spontaneous VT (CL 430 ms) in all 12 leads. Return CL measured at the pacing site showed a post pacing interval ≤30 ms (460 ms). Stimulus to QRS (250 ms, black arrow) was equal to the electrogram to QRS (250 ms, dotted arrow). The VT terminated after prolongation of CL. After this, the VT was not longer inducible. ABL d distal ablation catheter, ABL p proximal RF ablation catheter.
D. Prochnau, M. Hoyme / Journal of Electrocardiology xxx (2018) xxx–xxx
3
Fig. 2. Surface ECGs of different monomorphic ventricular tachyarrhythmias (VT) induced by programmed ventricular stimulation during electrophysiological studies.
zone of 500 ms). Renal function remained stable following RDN and there were no substantial changes in blood pressure. Discussion Predictors of VT recurrence after ablation include heart failure class, unstable VTs, persistent inducibility, and initial presentation with ES [6].
Failure to control recurrent VTs is associated with higher risk of subsequent death. Therefore, development of alternative treatment options is necessary to supress VTs in patients not being controlled with pharmacological and conventional catheter ablations [7]. As shown recently in smaller observational studies, RDN in order to modulate the sympathetic nervous system can reduce recurrent VTs [5,8]. Our report supports these findings. It demonstrates that RDN is an effective second-
Fig. 3. Electroanatomic voltage mapping (EnsiteNavX-System) with large inferior scar (right anterior and left anterior oblique view) before (A) and after (B) extensive substrate modification. Endocardium was mapped during sinus rhythm. Confluent areas of grey correspond to the dense infarct (bipolar volage b0.5 mV), purple correspond to normal tissue (bipolar voltage N1.5 mV), and the border zone in the „rainbow“of colours is in between. Panel C shows the three-dimensional reconstruction of both renal arteries with adjacent abdominal aorta. The red dots show the ablation points. Panel D,E, and F show angiography of the right renal artery after RDN (C), left renal artery during (D), and after RDN (F). No significant stenoses of the renal arteries were observed. Focal renal artery irregularities occurred immediately following RDN that were not flow limiting at procedure termination. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004
4
D. Prochnau, M. Hoyme / Journal of Electrocardiology xxx (2018) xxx–xxx
line treatment option in patients with ES and reduced LVEF when conventional catheter ablation and multiple medical treatment attempts failed to control the VTs. However, we cannot exclude that the substrate modification performed at the same time as the RDN was at least partially responsible for the treatment effect. Therefore, randomized trials are needed to evaluate the real impact of RDN in patients with recurrent VTs.
References [1] Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017, https://doi.org/10.1016/j. jacc.2017.10.054.
[2] Leenen FH. Cardiovascular consequences of sympathetic hyperactivity. Can J Cardiol 1999;15(Suppl. A):2A–7A. [3] Prochnau D, Romeike BF, Bischoff S, Schubert H, Figulla HR, Surber R. Reduction of neurofilaments following renal denervation with radiofrequency current in a sheep model. Int J Cardiol 2013;168:4450–2. [4] Schlaich MP, Sobotka PA, Krum H, Lambert E, Esler MD. Renal sympathetic-nerve ablation for uncontrolled hypertension. N Engl J Med 2009;361:932–4. [5] Armaganijan L2V, Staico R, Moreira DA, Lopes RD, Medeiros PT, Habib R, et al. 6Month outcomes in patients with implantable cardioverter-defibrillators undergoing renal sympathetic denervation for the treatment of refractory ventricular arrhythmias. JACC Cardiovasc Interv 2015;8:984–90. [6] Nagashima K, Choi EK, Tedrow UB, Koplan BA, Michaud GF, John RM, et al. Correlates and prognosis of early recurrence after catheter ablation for ventricular tachycardia due to structural heart disease. Circ Arrhythm Electrophysiol 2014;7:883–8. [7] Nayyar S, Ganesan AN, Brooks AG, Sullivan T, Roberts-Thomson KC, Sanders P. Venturing into ventricular arrhythmia storm: a systematic review and meta-analysis. Eur Heart J 2013;34:560–71. [8] Ukena C, Mahfoud F, Ewen S, Bollmann A, Hindricks G, Hoffmann BA, et al. Renal denervation for treatment of ventricular arrhythmias: data from an international multicenter registry. Clin Res Cardiol 2016;105:873–9.
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004
Contents lists available at ScienceDirect
Journal of Electrocardiology journal homepage: www.jecgonline.com
Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radiofrequency catheter ablation☆ Dirk Prochnau, MD ⁎, Matthias Hoyme, MD Department of Cardiology, Catholic “St. Johann Nepomuk” Hospital, Erfurt, Germany
a r t i c l e
i n f o
Available online xxxx Keywords: VT ablation Renal denervation Electrical storm Outcome
a b s t r a c t Electrical storm (ES) represents a critical state of electrical instability. We describe a patient with coronary artery disease, mechanical aortic valve replacement, and reduced left ventricular function with recurrent ICD shocks. Despite medical treatment with beta-blocker and amiodarone, and after successful ablation of different VT morphologies in combination with substrate modification, ES could not be controlled. We performed renal denervation (RDN) to reduce arrhythmic burden. Thereafter, patient remained free from sustained and non-sustained VTs at 6-month follow-up. RDN is an effective second-line treatment option in patients in whom conventional catheter ablation and medical treatment failed to control the VTs. © 2018 Elsevier Inc. All rights reserved.
Introduction Electrical storm (ES) represents a critical state of electrical instability in patients with cardiac diseases. It is characterized by several episodes of ventricular tachycardias (VT) within a short time. In patients with an implantable cardioverter-defibrillator (ICD) ES is defined as three or more appropriate VT detections within 24 h. Antiarrhythmic therapy and conventional radiofrequency (RF) catheter ablation are the standard of care in patients with VT and recurrent appropriate ICD shocks [1]. However, in some cases, these therapies are not able to control the VT. The autonomic nervous system plays an important role in the genesis and maintenance of arrhythmias [2]. It has been shown that renal denervation (RDN) can modify sympathetic nerve activity [3,4] and therefore reduce arrhythmic burden, especially if conventional catheter ablation of VT failed to control the arrhythmia [5]. The case An 82-year-old patient was admitted to our hospital because of recurrent appropriate ICD shocks. The patient had known coronary heart disease and severe reduced left ventricular ejection fraction (LVEF). Because of aortic stenosis patient had bileaflet mechanical aortic valve replacement in 2003. Comorbidity included type 2 diabetes mellitus and chronic renal insufficiency. Coronary angiography showed three-vessel coronary artery disease without significant stenosis after several coronary interventions. Despite treatment with beta-blocker ☆ Declarations of interest: None. ⁎ Corresponding author at: Catholic St. Johann Nepomuk Hospital, Haarbergstrasse 72, 99097 Erfurt, Germany. E-mail address: [email protected] (D. Prochnau).
and amiodarone in adequate dosages several episodes of VT recurred. Therefore, we decided to perform left ventricular (LV) radiofrequency (RF) ablation of VT using an antegrad-transseptal approach. Electroanatomic voltage mapping of the LV (EnsitePrecision cardiac mapping system, SJM, St. Paul, MN, USA) in sinus rhythm disclosed a large posterior and inferior scar area. During electrophysiological study a monomorphic VT was induced by programmed ventricular stimulation (PVS). After entrainment with perfect match (12/12), the VT could be ablated successfully in an antero-septal position of the LV (Fig. 1A). However, repeated PVS induced two badly tolerated VTs (Fig. 2). Therefore, we performed extensive substrate modification in the border zone of the scar after cardioversion of the VTs. The patient was discharged from hospital in stable condition under antiarrhythmic treatment with amiodarone and beta-blocker. Two weeks later the patient was again admitted with ES. Antiarrhythmic treatment was changed to sotalol and later to flecainid. This treatment remained without effect and second ablation of VT was performed. We could induce and ablate another monomorphic VT arising from an infero-apical position. After a perfect entrainment manoeuvre (Fig. 1B) it was ablated successfully until non-inducibility. Patient was referred to the intermediated care station. During the next days, the patient experienced recurrent sustained and non-sustained polymorphic VTs. Three days later, we decided to make a third ablation attempt. During this procedure, VT was not inducible. After extensive substrate modification around the large inferior infarct scar area of the LV (Fig. 3A and B), we performed RDN of both renal arteries as second-line option (Fig. 3C\\F). Three days later, the patient could be discharged from hospital in a stable condition. Antiarrhythmic treatment after discharge consisted of 10 mg bisoprolol and 300 mg amiodarone daily. Since that time, the patient remained stable in a good physical condition. ICD interrogation at 6-month FU found no more sustained or non-sustained VT (ICD with programmed VT-1
https://doi.org/10.1016/j.jelectrocard.2018.01.004 0022-0736/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004
2 D. Prochnau, M. Hoyme / Journal of Electrocardiology xxx (2018) xxx–xxx
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004
Fig. 1. Surface ECG and intracardiac recordings of monomorphic ventricular tachyarrhythmia (VT). (A) VT1 with perfect match (12/12) during entrainment manoeuvre in an antero-septal position. During ablation with an irrigated radiofrequency catheter at this position, VT terminated after increase in cycle length (CL). (B) VT2 with entrainment in an infero-apical position with perfect match. Entrainment from this site showed an exact match from spontaneous VT (CL 430 ms) in all 12 leads. Return CL measured at the pacing site showed a post pacing interval ≤30 ms (460 ms). Stimulus to QRS (250 ms, black arrow) was equal to the electrogram to QRS (250 ms, dotted arrow). The VT terminated after prolongation of CL. After this, the VT was not longer inducible. ABL d distal ablation catheter, ABL p proximal RF ablation catheter.
D. Prochnau, M. Hoyme / Journal of Electrocardiology xxx (2018) xxx–xxx
3
Fig. 2. Surface ECGs of different monomorphic ventricular tachyarrhythmias (VT) induced by programmed ventricular stimulation during electrophysiological studies.
zone of 500 ms). Renal function remained stable following RDN and there were no substantial changes in blood pressure. Discussion Predictors of VT recurrence after ablation include heart failure class, unstable VTs, persistent inducibility, and initial presentation with ES [6].
Failure to control recurrent VTs is associated with higher risk of subsequent death. Therefore, development of alternative treatment options is necessary to supress VTs in patients not being controlled with pharmacological and conventional catheter ablations [7]. As shown recently in smaller observational studies, RDN in order to modulate the sympathetic nervous system can reduce recurrent VTs [5,8]. Our report supports these findings. It demonstrates that RDN is an effective second-
Fig. 3. Electroanatomic voltage mapping (EnsiteNavX-System) with large inferior scar (right anterior and left anterior oblique view) before (A) and after (B) extensive substrate modification. Endocardium was mapped during sinus rhythm. Confluent areas of grey correspond to the dense infarct (bipolar volage b0.5 mV), purple correspond to normal tissue (bipolar voltage N1.5 mV), and the border zone in the „rainbow“of colours is in between. Panel C shows the three-dimensional reconstruction of both renal arteries with adjacent abdominal aorta. The red dots show the ablation points. Panel D,E, and F show angiography of the right renal artery after RDN (C), left renal artery during (D), and after RDN (F). No significant stenoses of the renal arteries were observed. Focal renal artery irregularities occurred immediately following RDN that were not flow limiting at procedure termination. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004
4
D. Prochnau, M. Hoyme / Journal of Electrocardiology xxx (2018) xxx–xxx
line treatment option in patients with ES and reduced LVEF when conventional catheter ablation and multiple medical treatment attempts failed to control the VTs. However, we cannot exclude that the substrate modification performed at the same time as the RDN was at least partially responsible for the treatment effect. Therefore, randomized trials are needed to evaluate the real impact of RDN in patients with recurrent VTs.
References [1] Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017, https://doi.org/10.1016/j. jacc.2017.10.054.
[2] Leenen FH. Cardiovascular consequences of sympathetic hyperactivity. Can J Cardiol 1999;15(Suppl. A):2A–7A. [3] Prochnau D, Romeike BF, Bischoff S, Schubert H, Figulla HR, Surber R. Reduction of neurofilaments following renal denervation with radiofrequency current in a sheep model. Int J Cardiol 2013;168:4450–2. [4] Schlaich MP, Sobotka PA, Krum H, Lambert E, Esler MD. Renal sympathetic-nerve ablation for uncontrolled hypertension. N Engl J Med 2009;361:932–4. [5] Armaganijan L2V, Staico R, Moreira DA, Lopes RD, Medeiros PT, Habib R, et al. 6Month outcomes in patients with implantable cardioverter-defibrillators undergoing renal sympathetic denervation for the treatment of refractory ventricular arrhythmias. JACC Cardiovasc Interv 2015;8:984–90. [6] Nagashima K, Choi EK, Tedrow UB, Koplan BA, Michaud GF, John RM, et al. Correlates and prognosis of early recurrence after catheter ablation for ventricular tachycardia due to structural heart disease. Circ Arrhythm Electrophysiol 2014;7:883–8. [7] Nayyar S, Ganesan AN, Brooks AG, Sullivan T, Roberts-Thomson KC, Sanders P. Venturing into ventricular arrhythmia storm: a systematic review and meta-analysis. Eur Heart J 2013;34:560–71. [8] Ukena C, Mahfoud F, Ewen S, Bollmann A, Hindricks G, Hoffmann BA, et al. Renal denervation for treatment of ventricular arrhythmias: data from an international multicenter registry. Clin Res Cardiol 2016;105:873–9.
Please cite this article as: Prochnau D, Hoyme M, Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radio..., Journal of Electrocardiology (2018), https://doi.org/10.1016/j.jelectrocard.2018.01.004