Key result
Epicardial substrate ablation cuts VF burden by ~99% in symptomatic Brugada syndrome.
Why the study?
Treatment options for high-risk Brugada syndrome with recurrent ventricular fibrillation are limited, and large studies with long-term outcome data on catheter ablation are lacking.
Does epicardial substrate ablation reduce ventricular fibrillation recurrence in high-risk patients with symptomatic Brugada syndrome?
Cohort (n=159)
Yes
Does epicardial substrate ablation reduce ventricular fibrillation recurrence in high-risk patients with symptomatic Brugada syndrome?
Epicardial substrate ablation safely and highly effectively prevents ventricular fibrillation recurrences in high-risk patients with Brugada syndrome, almost eliminating the need for subsequent ICD shocks.
Answers are grounded in this paper and cite their sources.
Epicardial ablation was associated with VF reduction in symptomatic Brugada syndrome; leaves open whether randomized trials will confirm benefit and change practice.
Background: Treatment options for high-risk Brugada syndrome (BrS) with recurrent ventricular fibrillation (VF) are limited. Catheter ablation is increasingly performed but a large study with long-term outcome data is lacking. We report the results of the multicenter, international BRAVO (Brugada Ablation of VF Substrate Ongoing Registry) for treatment of high-risk symptomatic BrS. Methods: We enrolled 159 patients (median age 42 years; 156 male) with BrS and spontaneous VF in BRAVO; 43 (27%) of them had BrS and early repolarization pattern. All but 5 had an implantable cardioverter-defibrillator for cardiac arrest (n=125) or syncope (n=34). A total of 140 (88%) had experienced numerous implantable cardioverter-defibrillator shocks for spontaneous VF before ablation. All patients underwent a percutaneous epicardial substrate ablation with electroanatomical mapping except for 8 who underwent open-thoracotomy ablation. Results: In all patients, VF/BrS substrates were recorded in the epicardial surface of the right ventricular outflow tract; 45 (29%) patients also had an arrhythmic substrate in the inferior right ventricular epicardium and 3 in the posterior left ventricular epicardium. After a single ablation procedure, 128 of 159 (81%) patients remained free of VF recurrence; this number increased to 153 (96%) after a repeated procedure (mean 1.2±0.5 procedures; median=1), with a mean follow-up period of 48±29 months from the last ablation. VF burden and frequency of shocks decreased significantly from 1.1±2.1 per month before ablation to 0.003±0.14 per month after the last ablation ( P <0.0001). The Kaplan-Meier VF-free survival beyond 5 years after the last ablation was 95%. The only variable associated with a VF-free outcome in multivariable analysis was normalization of the type 1 Brugada ECG, both with and without sodium-channel blockade, after the ablation (hazard ratio, 0.078 [95% CI, 0.008 to 0.753]; P =0.0274). There were no arrhythmic or cardiac deaths. Complications included hemopericardium in 4 (2.5%) patients. Conclusions: Ablation treatment is safe and highly effective in preventing VF recurrence in high-risk BrS. Prospective studies are needed to determine whether it can be an alternative treatment to implantable cardioverter-defibrillator implantation for selected patients with BrS. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04420078.
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Nademanee et al. (2023) conducted a cohort in High-risk Brugada syndrome with spontaneous ventricular fibrillation (n=159). Percutaneous epicardial substrate ablation vs. Pre-ablation baseline (intra-patient control) was evaluated on Ventricular fibrillation burden (events per month) (p=<0.0001). Epicardial substrate ablation significantly reduced ventricular fibrillation burden from 1.1 to 0.003 events per month (P<0.0001) in patients with symptomatic Brugada syndrome.
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