Ablation of frequent premature ventricular complex allows safe withholding of ICD implant

Diego Penela
Diego Penela

Patients with frequent premature ventricular complex and primary prevention implantable cardioverter defibrillator (ICD) indication who undergo ablation may be able to avoid ICD implant, according to research presented at CARDIOSTIM-EHRA EUROPACE (8‒11 June, Nice, France).

The paper, which has been previously published in HeartRhythm, won best European Heart Rhythm Association (EHRA) Young EP Research at CARDIOSTIM-EHRA EUROPACE 2016 among over 30 papers submitted for competition to the “Best research by young electrophysiologists” session. Four papers were presented in total.

Commenting on the outcomes of the study, first author Diego Penela (Hospital Clinic and IDIBAPS, Barcelona, Spain) told Cardiac Rhythm News: “If you have a patient with frequent premature ventricular complex and primary prevention ICD indication you must first ablate, withhold the ICD implant and re-evaluate the implantation during the first to sixth month post ablation. This seems to be an appropriate and safe strategy.”

Speaking on the clinical implications and value of this study, co-chair of the EHRA Young EP committee 2015-2017, Valentina Kutfiya (University of Rochester Medical Center, Rochester, USA), said: “This paper was very intriguing because it suggested that catheter ablation for frequent premature ventricular complex will improve the ejection fraction to a degree that an ICD is not needed. We all know that implantation of an ICD is also associated with potential long-term issues, especially with leads. This strategy could also potentially cut costs. Therefore, if we can avoid ICD implant with a one-time ablation procedure there is an important clinical impact for the future.”

The multicentre prospective study included 66 consecutive patients with primary prevention ICD indication and frequent premature ventricular complex (50% men; mean age 53±13 years). Seventeen per cent of the patients had ischaemic heart disease.
Penela explained that the patients underwent catheter ablation guided by the CARTO navigation system (Biosense Webster) using a 3.5mm irrigated-tip catheter (Navistar, Biosense Webster) for mapping and ablation. The ICD implant was withheld and indication was re-evaluated at six and 12 months post ablation.

“Current guidelines recommend withholding the implant in some circumstances as, for instance, after surgical myocardial revascularisation, with the assumption that left ventricular ejection fraction (LVEF) could improve. However, there are no specific timing recommendations on the re-evaluation of LVEF and the subsequent decision to proceed with the ICD after ablation of frequent premature ventricular complex in patients meeting primary prevention ICD criteria,” write Penela et al in HeartRhythm.

In this study, LVEF improved after ablation from 28%±4% at baseline to 42%±12% at 12 months (p<.001). Additionally, also at 12 months, New York Heart Association (NYHA) functional class improved from two patients with NYHA functional class I (3%) at baseline to 35 (53%), from 43 patients with NYHA functional class II (65%) at baseline to 23 (35%) and from 21 patients with NYHA functional class III (32%) at baseline to 4 (6%).

There was also a significant reduction in BNP level from 246±187 pg/mL at baseline to 176±380 pg/mL at 12 months. “This significant improvement resulted in 64% of patients no longer meeting primary prevention ICD criteria at the end of follow-up. Penela et al highlighted that “in patients with a high baseline premature ventricular complex burden and acute successful ablation, the rate of removing the indication significantly improves (up to 91%) and reaches 97% in patients with successful sustained ablation.”

“A baseline premature ventricular complex burden ≥13% is the best cut-off for removing primary prevention ICD indication after ablation,” Penela commented.

No sudden cardiac deaths or malignant ventricular arrhythmias were observed.

About EHRA Young EP

The “Best research by young electrophysiologists” session is one of the initiatives led by the EHRA Young EP committee, which aims to promote the work of young electrophysiologists (out of training until the age of 40, or no more than three years out of training if over 40), and create a global network within the scientific EP community to assist with non-­clinical professional training needs.

Criteria to select the best paper for this competition were based on the impact factor of the journal where the study was published, originality and findings. The winner was awarded with a travel grant from EHRA to attend CARDIOSTIM-EHRA EUROPACE 2016.
The EHRA Young EP committee members 2015‒2017 are: chair Tom De Potter (OLV Hospital Aalst, Gent, Belgium), co-chair Valentina Kutyifa (University of Rochester Medical Center, Rochester, USA), Elena Arbelo (Cardiothoracic Institute of the Hospital Clinic, Barcelona, Spain) Sergey Barsamyan (Oxford University Hospitals, Oxford, UK) and Jedrzej Koziuk (Heart Center Leipzig, Germany).

Click here to find more about EHRA Young EP.