Local activation time guided versus anatomical approach for ablation of premature ventricular complexes originating from the cardiac base
N Tsianakas, P Bengel, P Huisl, N Schneider, P Starcke, S Sossalla, B DinovAbstract
Background
Premature ventricular complexes (PVCs) arising from the basal regions of the heart remain a challenging target for catheter ablation (CA). Local-activation-time (LAT)-guided ablation targeting the earliest activation is considered the standard approach but is not always feasible. An alternative strategy of CA targeting adjacent anatomical structures to the PVC earliest activation site can be useful when the LAT-guided approach fails. The acute and long-term effectiveness of the anatomical approach (AA) is less well-studied.
Methods
We conducted a retrospective, single-centre study including patients with symptomatic, high-burden PVCs originating from the right-ventricular outflow tract (RVOT), the left-ventricular outflow tract (LVOT), the distal coronary sinus (CS), or the aorto-mitral continuity (AMC). Median follow-up was 107 days (IQR 65–343 days). A total of 48 patients undergoing either LAT-guided ablation or AA were included. Overall, 56% (n=27) underwent LAT-guided ablation, whereas 44% (n=21) underwent AA. In the LAT group, 56% (n=15) were female compared to 19% in the anatomical group (p=0.01). Left-ventricular ejection fraction was comparable between groups (LAT 55%±11% and AA 49%±11.6%, p=0.09). Monomorphic PVCs were more frequent in the LAT group: 23 (62%) vs. 14 (38%) in the AA group (p=0.13).
Results
Acute success was achieved in all patients (100%) in the LAT group compared to 17 patients (71%) in the anatomical group (p=0.019). In the overall cohort, PVC burden was reduced from 20.4%±10% to 5.7%±7.9% (p=0.0001). In the LAT group, PVC burden decreased from 17%±10% to 2.6%±4.04% (p=0.006), and in the AA group from 23%±9.9% to 8.15%±9.6% (p=0.018). Long-term recurrence during follow-up occurred in 32% of the LAT group versus 54% of the anatomical group (p=0.21).
Conclusion
Anatomical ablation for PVCs originating from the basal regions of the heart was feasible and acutely successful in many patients. A significant reduction in PVC burden was observed in both treatment strategies; however, anatomical ablation was associated with worse long-term outcomes than LAT-guided ablation for PVCs arising from the cardiac base.