Radiofrequency Ablation of Asymptomatic Brugada Syndrome
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.117.032624
ISSN1524-4539
Autores Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 137, No. 18Radiofrequency Ablation of Asymptomatic Brugada Syndrome Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBRadiofrequency Ablation of Asymptomatic Brugada SyndromeDon't Go Burning My Heart Sami Viskin, MD Sami ViskinSami Viskin Tel-Aviv Medical Center, Sackler School of Medicine, Tel-Aviv University, Israel. Originally published12 Mar 2018https://doi.org/10.1161/CIRCULATIONAHA.117.032624Circulation. 2018;137:1883–1884Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 1, 2018: Previous Version 1 Terror mori ex abrupto is the Latin term for "fear of dropping dead." Based on frequent email consultations I receive from patients with suspected Brugada syndrome (BrS), it seems that a terrifying anticipation of dying is more dominant among asymptomatic patients with BrS than in other arrhythmogenic diseases. The tragic death of a young British man that went viral over Facebook, led >10 000 British citizens to petition their Parliament, requesting that all patients with asymptomatic BrS be given the choice of an implantable defibrillator (ICD), even in the absence of markers indicating increased risk. One in 2 patients undergoing ICD implantation for BrS are asymptomatic and 1 in 5 are not only free of symptoms, but do not even have the Brugada ECG spontaneously.1,2 Given that fatal arrhythmias are particularly rare in the last category of patients (see below), it is obvious that many patients and physicians are willing to do whatever it takes, instead of whatever is best, to avoid the rare occurrence of cardiac arrest, even if this involves some potentially serious complications related to ICD implantation. It is therefore not surprising that an increasing number of asymptomatic patients are opting to undergo a radiofrequency (RF) ablation procedure with the hope of curing their disease.RF ablation of the arrhythmic substrate in BrS was first described by Nademanee et al3 in a landmark publication in Circulation 6 years ago. The procedure involves percutaneous needle access of the pericardial space and catheter ablation of areas of abnormal (low-voltage/fractionated) potentials, believed to represent zones of interstitial fibrosis and reduced gap-junction expression, on the right ventricular outflow.3 The procedure, as originally proposed,3 was intended for patients who experienced multiple ICD shocks because of recurrent ventricular fibrillation (VF).3 More recently, however, other groups broadened the indication of the procedure as a form of cure for asymptomatic patients.4 As for the whatever-it-takes approach described above for ICD implantation, 53% of patients undergoing RF ablation, in a recent publication,4 had no arrhythmia-related symptoms, and 77% of the asymptomatic group (41% of patients undergoing epicardial ablation) had neither arrhythmia-related symptoms nor a spontaneous type I Brugada ECG.Moving back to a whatever-is-best approach, what are the therapeutic options for asymptomatic BrS?(1) No therapy is a reasonable option for well-informed patients without ECG features associated with higher risk,5 as long as they appreciate that the risk is low, but not zero. In series with >10 years of follow-up, the risk of spontaneous VF was ≈1% per year for asymptomatic patients with spontaneous type I ECG and ≤0.5% per year1,2 when the Brugada ECG was revealed by a drug challenge. It is important to note that these figures mainly represent patients receiving appropriate ICD shocks for VF and are likely to overestimate the real risk of cardiac arrest. Limited data5 suggest that the risk of cardiac arrest for asymptomatic patients without ICD could be lower. Thus, the best estimate of risk of cardiac arrest that we can quote for our asymptomatic patients is <1% per year, noting that we cannot accurately estimate less by how much. Because all of us would like to eliminate this risk, the real question is: what is the price that we are prepared to pay, in terms of adverse events directly caused by our preventive therapies, to achieve this goal.(2) Quinidine therapy. In QUIDAM (Hydroquinidine Versus Placebo in Patients With Brugada Syndrome), a crossover trial of quinidine versus placebo in high-risk patients with BrS that was terminated prematurely, the annual risk of VF was 1% for patients on placebo and zero during quinidine therapy (P=not significant). Quinidine has been effective in preventing spontaneous VF in patients with inducible VF and in preventing VF recurrence during arrhythmic storm. Quinidine therapy is therefore a reasonable option for asymptomatic patients with a spontaneous type I ECG, in particular, for those with high-risk features like QRS fragmentation or short-coupled extrasystoles.5 Long-QT–related proarrhythmic events from quinidine are unexpected in a predominantly male population. However, diarrhea, thrombocytopenia, and liver damage are important side effects.(3) ICD implantation offers the best protection against arrhythmic death at the expense of complications (including serious infections and painful inappropriate shocks), reported in 18% to 36% of patients.1 Inappropriate shocks are also a complication of the newer subcutaneous ICD.(4) RF ablation. Although the effectiveness of RF ablation for preventing VF recurrence following arrhythmic storm was originally reported as being 100%,3 with longer follow-up periods VF recurred in 1 of 9 patients (K. Nademanee, MD, unpublished data, 2017). Similarly, 5% of patients who had VF before the ablation in a larger study developed ventricular arrhythmias within 1 year of the procedure (including 1 with recurrent VF).4 The absence of VF among the 72 patients with asymptomatic BrS4 is of limited significance because only 0 to 1 of similar yet untreated patients would be predicted to develop arrhythmias within such a short follow-up period.5 Normalization of the ECG, an end point of RF ablation,3,4 although rewarding, must be interpreted with caution because, in general, 1:4 of patients with BrS presenting with cardiac arrest have a normal ECG at presentation.1 Similar caution must be exerted when reviewing the excellent safety record reported so far for the ablation of BrS.1,4 In larger series of patients undergoing epicardial ablation for miscellaneous reasons, complications include needle puncture of the right ventricle in ≈10% of patients, tamponade in ≈5%, and injury to abdominal viscera or coronary arteries in ≈1%. It would be difficult to justify such complications if they occur to asymptomatic patients. It is important to note that the procedure performed nowadays involves ablation of more extensive areas of the right ventricle,4 raising concern for future proarrhythmic events related to gaps within lesions in the ablated areas.RF ablation of BrS may well be a life-saving procedure for patients with VF storm. The procedure should be reserved, at least for now, for patients with symptomatic BrS. Until we learn more about its effectiveness and safety, asymptomatic patients requesting ablation should, in my personal opinion, hear the alternative lyrics by Elton John and Kiki Dee: "Don't go burning your heart…." Not yet!DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.http://circ.ahajournals.orgSami Viskin, MD, Tel-Aviv Medical Center, Weizman 6, Tel-Aviv 6423919, Israel. E-mail [email protected]References1. Sacher F, Probst V, Maury P, Babuty D, Mansourati J, Komatsu Y, Marquie C, Rosa A, Diallo A, Cassagneau R, Loizeau C, Martins R, Field ME, Derval N, Miyazaki S, Denis A, Nogami A, Ritter P, Gourraud JB, Ploux S, Rollin A, Zemmoura A, Lamaison D, Bordachar P, Pierre B, Jaïs P, Pasquié JL, Hocini M, Legal F, Defaye P, Boveda S, Iesaka Y, Mabo P, Haïssaguerre M. Outcome after implantation of a cardioverter-defibrillator in patients with Brugada syndrome: a multicenter study-part 2.Circulation. 2013; 128:1739–1747. doi: 10.1161/CIRCULATIONAHA.113.001941.LinkGoogle Scholar2. Sieira J, Ciconte G, Conte G, de Asmundis C, Chierchia GB, Baltogiannis G, Di Giovanni G, Saitoh Y, Casado-Arroyo R, Juliá J, La Meir M, Wellens F, Wauters K, Pappaert G, Brugada P. Long-term prognosis of drug-induced Brugada syndrome.Heart Rhythm. 2017; 14:1427–1433. doi: 10.1016/j.hrthm.2017.04.044.CrossrefMedlineGoogle Scholar3. Nademanee K, Veerakul G, Chandanamattha P, Chaothawee L, Ariyachaipanich A, Jirasirirojanakorn K, Likittanasombat K, Bhuripanyo K, Ngarmukos T. Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium.Circulation. 2011; 123:1270–1279. doi: 10.1161/CIRCULATIONAHA.110.972612.LinkGoogle Scholar4. Pappone C, Brugada J, Vicedomini G, Ciconte G, Manguso F, Saviano M, Vitale R, Cuko A, Giannelli L, Calovic Z, Conti M, Pozzi P, Natalizia A, Crisà S, Borrelli V, Brugada R, Sarquella-Brugada G, Guazzi M, Frigiola A, Menicanti L, Santinelli V. Electrical substrate elimination in 135 consecutive patients with brugada syndrome.Circ Arrhythm Electrophysiol. 2017; 10:e005053. doi: 10.1161/CIRCEP.117.005053.LinkGoogle Scholar5. Adler A, Rosso R, Chorin E, Havakuk O, Antzelevitch C, Viskin S. Risk stratification in Brugada syndrome: clinical characteristics, electrocardiographic parameters, and auxiliary testing.Heart Rhythm. 2016; 13:299–310. doi: 10.1016/j.hrthm.2015.08.038.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByViskin S, Chorin E, Viskin D, Hochstadt A, Schwartz A and Rosso R (2021) Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy, Circulation, 144:10, (823-839), Online publication date: 7-Sep-2021. Viskin S, Chorin E and Rosso R (2021) The top 10 reasons to avoid electrophysiology studies in Brugada syndrome, Heart Rhythm, 10.1016/j.hrthm.2021.01.013, 18:5, (672-673), Online publication date: 1-May-2021. Viskin S, Hochstadt A, Schwartz A and Rosso R (2021) Will I Die From Brugada Syndrome?, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2020.09.005, 7:2, (223-225), Online publication date: 1-Feb-2021. Schwartz P, Ackerman M, Antzelevitch C, Bezzina C, Borggrefe M, Cuneo B and Wilde A (2020) Inherited cardiac arrhythmias, Nature Reviews Disease Primers, 10.1038/s41572-020-0188-7, 6:1, Online publication date: 1-Dec-2020. Campuzano O, Sarquella-Brugada G, Brugada R and Brugada J (2020) Brugada Syndrome Clinical Cardiogenetics, 10.1007/978-3-030-45457-9_14, (231-246), . Aloia E (2018) Letter by Aloia Regarding Article, "Radiofrequency Ablation of Asymptomatic Brugada Syndrome: Don't Go Burning My Heart", Circulation, 138:22, (2582-2583), Online publication date: 27-Nov-2018.Viskin S (2018) Response by Viskin to Letter Regarding Article, "Radiofrequency Ablation of Asymptomatic Brugada Syndrome: Don't Go Burning My Heart", Circulation, 138:22, (2584-2585), Online publication date: 27-Nov-2018.Viskin S, Hochstadt A and Rosso R (2018) Type‐I Paradox of Brugada Syndrome, Journal of the American Heart Association, 7:10, Online publication date: 15-May-2018. Corrado D, Link M and Schwartz P (2022) Implantable defibrillators in primary prevention of genetic arrhythmias. A shocking choice?, European Heart Journal, 10.1093/eurheartj/ehac298 May 1, 2018Vol 137, Issue 18 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.032624PMID: 29530885 Originally publishedMarch 12, 2018 Keywordscatheter ablationarrhythmias, cardiacheart arrestdefibrillators, implantableBrugada syndromeelectrocardiographyPDF download Advertisement SubjectsSudden Cardiac Death
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