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Substrate Imaging Before Catheter Ablation of VT
Quick Takes
- A CT-derived scar volume has significant association for acute hemodynamic decompensation among patients presenting for VT ablation.
- These data suggest that incorporation of total scar volume into PAINESD may help identify patients with significant scar burden who may have otherwise been classified as having low or intermediate risk.
- The predictability of periprocedural acute hemodynamic decompensation may help identify patients that might require mechanical hemodynamic support preemptively.
Study Questions:
What is the impact of total scar volume (TSV) on the risk of acute hemodynamic decompensation (AHD) and its adjunctive benefit to the PAINESD score newly modified as Pulmonary disease, Age, Ischemic cardiomyopathy, NYHA class, Ejection fraction, Storm, Scar volume, Diabetes mellitus (PAINES2D) based on the addition of scar volumes?
Methods:
The investigators conducted a retrospective analysis of all index VT ablations at a quaternary care center from 2017–2022. Associations between TSV and AHD were evaluated among patients with structural heart disease. All patients underwent advanced cardiac computed tomography (CT) imaging before ablation using a novel method for assessment of wall thinning and scar. Imaging was performed using late iodine enhancement (LIE) for scar characterization on a third-generation dual-source CT system. The primary procedural endpoint was occurrence of AHD during VT ablation that required advanced hemodynamic support, which included chemical support (≥2 vasopressors) and/or mechanical support and monitoring. The acute decompensation predictability values of the PAINESD and PAINES2D scores were compared via univariate logistic regression models using receiver-operating characteristic curves based on model probabilities.
Results:
Among 61 patients with TSV data, 13 (21%) had periprocedural AHD. TSV and PAINESD were independently associated with AHD risk. Both TSV and PAINESD were associated with AHD (p = 0.016 vs. p = 0.053, respectively). The highest TSV tertile (≥37.30 mL) showed significant association with AHD (p = 0.018; odds ratio, 4.80) compared to the other tertiles. The PAINESD and PAINES2D scores had significant impact on AHD (p = 0.046 and p = 0.010, respectively). The PAINES2D score had a greater impact on AHD compared to PAINESD (area under the curve, 0.73; p = 0.011; 95% confidence interval [CI], 0.56-0.91 and area under the curve, 0.67; p = 0.058; 95% CI, 0.49-0.85, respectively).
Conclusions:
The authors report that the addition of TSV to a modified PAINESD score (PAINES2D) enhances risk prediction of AHD.
Perspective:
This study reports that a CT-derived scar volume has significant association for AHD among patients presenting for VT ablation. These data suggest that incorporation of TSV into PAINESD may help identify patients with significant scar burden who may have otherwise been classified as having low or intermediate risk and may be particularly useful in the nonischemic cohort. The predictability of periprocedural AHD may help identify patients who might require mechanical hemodynamic support preemptively. The ability to identify such patients accurately can help minimize the incidence of AHD and procedure times as well as optimize overall cost-effectiveness. Given the small sample size, additional studies in larger cohorts are indicated to validate these early findings.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Arrhythmias, Cardiac, Cardiomyopathies, Catheter Ablation, Cicatrix, Computed Tomography, Diabetes Mellitus, Heart Failure, Hemodynamics, Lung Diseases, Myocardial Ischemia, Risk, Secondary Prevention, Stroke Volume, Tachycardia, Ventricular
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