The Association of Clustered Ventricular Arrhythmia and Cycle Length With Scar Burden in Cardiomyopathy

Rachit M Vakil, Joseph E Marine, Aravindan Kolandaivelu, Timm Dickfeld, Robert G Weiss, Gordon F Tomaselli, Jonathan Chrispin, Katherine C Wu, Rachit M Vakil, Joseph E Marine, Aravindan Kolandaivelu, Timm Dickfeld, Robert G Weiss, Gordon F Tomaselli, Jonathan Chrispin, Katherine C Wu

Abstract

Background: Patients with ≥2 ventricular arrhythmia (VA) events within 3 months (clustered VA) have increased risk for mortality.

Objectives: The aim of this study was to examine the association of risk factors including scar characteristics on cardiovascular magnetic resonance imaging with clustered VA and VA cycle length in nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM).

Methods: Data from 329 primary prevention implantable cardioverter-defibrillator recipients (mean age 57 years, 26% women) were analyzed from the Left Ventricular Structural Predictors of Sudden Cardiac Death study.

Results: Twenty-one patients developed clustered VA (median time 2.7 years after implantable cardioverter-defibrillator placement). Men had the greatest risk for recurrent VA. Patients with NICM and scar had the highest incidence rate of clustered VA. In patients with NICM, each 1-g increase in core scar correlated with greater clustered VA risk (HR: 1.19; 95% CI: 1.07-1.32). Gray scar was similar among subgroups. Patients with NICM with clustered VA had the longest mean VA cycle length (297 ± 40 milliseconds). Higher core scar burden correlated with longer VA cycle length in patients with NICM (P = 0.002), and higher body mass index correlated with shorter VA cycle length in those with ICM (P = 0.02). Type of VA was similar between cardiomyopathy subgroups, and no scar pattern predominated.

Conclusions: Clustered VA was most common in patients with NICM and scar, with greatest risk among those with larger core scar. Core scar correlated with slower VA in patients with NICM, and higher body mass index correlated with faster VA in those with ICM. Type of VA was similar by cardiomyopathy etiology, and no dominant scar pattern was associated with clustered VA.

Keywords: cardiovascular magnetic resonance; risk stratification; sudden cardiac death; ventricular arrhythmia.

Conflict of interest statement

Funding Support and Author Disclosures This work was supported by National Heart, Lung, and Blood Institute grant R01HL103812 (to Dr Wu) and National Heart, Lung, and Blood Institute grant R01HL132181 (to Drs Wu and Tomaselli). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

FIGURE 1. Cumulative Incidence of Clustered VA…
FIGURE 1. Cumulative Incidence of Clustered VA Stratified by Type of Cardiomyopathy
Patients with nonischemic cardiomyopathy (NICM) and core scar have the highest cumulative incidence of clustered ventricular arrhythmia (VA). ICM = ischemic cardiomyopathy.
FIGURE 2. Proportional Frequency of VA Type…
FIGURE 2. Proportional Frequency of VA Type Stratified by Cardiomyopathy and Clustered VA
Monomorphic ventricular tachycardia (MMVT) was the most common type of ventricular arrhythmia (VA) event among the 4 subgroups of clustered VA and cardiomyopathy. The nonischemic cardiomyopathy with clustered VA subgroup had the most amount of polymorphic ventricular tachycardia (PMVT). VF = ventricular fibrillation; VFlutter = ventricular flutter.
FIGURE 3. Proportional Frequency of Scar Pattern…
FIGURE 3. Proportional Frequency of Scar Pattern in Patients With Nonischemic Cardiomyopathy Stratified by Clustered VA
Subepicardial and subendocardial scars were more prevalent than other patterns in the nonischemic cardiomyopathy with clustered ventricular arrhythmia (VA) subgroup, but no single scar pattern predominated. RV insert = right ventricular insertion point.
FIGURE 4. Proportional Frequency of Scar Location…
FIGURE 4. Proportional Frequency of Scar Location in Patients With Nonischemic Cardiomyopathy Stratified by Clustered VA
The septal, inferior, and lateral walls were more commonly affected by scar in the nonischemic cardiomyopathy with clustered ventricular arrhythmia (VA) subgroup, but no single scar location was most affected.
CENTRAL ILLUSTRATION. Core Scar on Cardiovascular Magnetic…
CENTRAL ILLUSTRATION. Core Scar on Cardiovascular Magnetic Resonance Imaging Is Associated With Clustered Ventricular Arrhythmia in Patients With Nonischemic Cardiomyopathy
CMR = cardiovascular magnetic resonance; ICM = ischemic cardiomyopathy; NICM = nonischemic cardiomyopathy; VA = ventricular arrhythmia.

References

    1. Fries R, Heisel A, Huwer H, et al. Incidence and clinical significance of short-term recurrent ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillator. Int J Cardiol. 1997;59:281–284.
    1. Elsokkari I, Parkash R, Tang A, et al. Mortality risk increases with clustered ventricular arrhythmias in patients with implantable cardioverter-defibrillators. J Am Coll Cardiol EP. 2020;6:327–337.
    1. Guerra F, Shkoza M, Scappini L, Flori M, Capucci A. Role of electrical storm as a mortality and morbidity risk factor and its clinical predictors: a meta-analysis. Europace. 2014;16:347–353.
    1. Scott PA, Rosengarten JA, Curzen NP, Morgan JM. Late gadolinium enhancement cardiac magnetic resonance imaging for the prediction of ventricular tachyarrhythmic events: a meta-analysis. Eur J Heart Fail. 2013;15:1019–1027.
    1. Disertori M, Rigoni M, Pace N, et al. Myocardial fibrosis assessment by LGE is a powerful predictor of ventricular tachyarrhythmias in ischemic and nonischemic LV dysfunction: a meta-analysis. J Am Coll Cardiol Img. 2016;9:1046–1055.
    1. Di Marco A, Anguera I, Schmitt M, et al. Late gadolinium enhancement and the risk for ventricular arrhythmias or sudden death in dilated cardiomyopathy: systematic review and meta-analysis. J Am Coll Cardiol HF. 2017;5:28–38.
    1. Wu KC, Gerstenblith G, Guallar E, et al. Combined cardiac magnetic resonance imaging and C-reactive protein levels identify a cohort at low risk for defibrillator firings and death. Circ Cardiovasc Imaging. 2012;5:178–186.
    1. Wu KC. Sudden cardiac death substrate imaged by magnetic resonance imaging: from investigational tool to clinical applications. Circ Cardiovasc Imaging. 2017;10:e005461.
    1. Schmidt A, Azevedo CF, Cheng A, et al. Infarct tissue heterogeneity by magnetic resonance imaging identifies enhanced cardiac arrhythmia susceptibility in patients with left ventricular dysfunction. Circulation. 2007;115:2006–2014.
    1. Wu KC, Weiss RG, Thiemann DR, et al. Late gadolinium enhancement by cardiovascular magnetic resonance heralds an adverse prognosis in nonischemic cardiomyopathy. J Am Coll Cardiol. 2008;51:2414–2421.
    1. Almehmadi F, Joncas SX, Nevis I, et al. Prevalence of myocardial fibrosis patterns in patients with systolic dysfunction: prognostic significance for the prediction of sudden cardiac arrest or appropriate implantable cardiac defibrillator therapy. Circ Cardiovasc Imaging. 2014;7:593–600.
    1. Klem I, Klein M, Khan M, et al. Relationship of LVEF and myocardial scar to long-term mortality risk and mode of death in patients with non-ischemic cardiomyopathy. Circulation. 2021;143:1343–1358.
    1. Wijnmaalen AP, Schalij MJ, von der Thüsen JH, Klautz RJ, Zeppenfeld K. Early reperfusion during acute myocardial infarction affects ventricular tachycardia characteristics and the chronic electroanatomic and histological substrate. Circulation. 2010;121:1887–1895.
    1. Lo R, Chia KK, Hsia HH. Ventricular tachycardia in ischemic heart disease. Card Electrophysiol Clin. 2017;9:25–46.
    1. Okada DR, Miller J, Chrispin J, et al. Substrate spatial complexity analysis for the prediction of ventricular arrhythmias in patients with ischemic cardiomyopathy. Circ Arrhythm Electrophysiol. 2020;13:e007975.
    1. McCrohon J, Moon J, Prasad S, et al. Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance. Circulation. 2003;108:54–59.
    1. Becker MA, Cornel JH, Van de Ven PM, van Rossum AC, Allaart CP, Germans T. The prognostic value of late gadolinium-enhanced cardiac magnetic resonance imaging in nonischemic dilated cardiomyopathy: a review and meta-analysis. J Am Coll Cardiol Img. 2018;11:1274–1284.
    1. Nakahara S, Tung R, Ramirez RJ, et al. Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy: implications for catheter ablation of hemodynamically unstable ventricular tachycardia. J Am Coll Cardiol. 2010;55:2355–2365.
    1. Shin DG, Lee H-J, Park J, et al. Pattern of late gadolinium enhancement predicts arrhythmic events in patients with non-ischemic cardiomyopathy. Int J Cardiol. 2016;222:9–15.
    1. Kim SK, Bennett R, Ingles J, Kumar S, Zaman S. Arrhythmia in cardiomyopathy: sex and gender differences. Curr Heart Fail Rep. 2021;18(5):274–283.
    1. Pietrasik G, Goldenberg I, McNitt S, Moss AJ, Zareba W. Obesity as a risk factor for sustained ventricular tachyarrhythmias in MADIT II patients. J Cardiovasc Electrophysiol. 2007;18:181–184.
    1. Maffei á, Halaas J, Ravussin E, et al. Leptin levels in human and rodent: measurement of plasma leptin and ob RNA in obese and weight-reduced subjects. Nat Med. 1995;1:1155–1161.
    1. Aronis KN, Ali RL, Prakosa A, et al. Accurate conduction velocity maps and their association with scar distribution on magnetic resonance imaging in patients with postinfarction ventricular tachycardias. Circ Arrhythm Electrophysiol. 2020;13:e007792.
    1. Nishimura T, Upadhyay GA, Aziz ZA, et al. Circuit determinants of ventricular tachycardia cycle length: characterization of fast and unstable human ventricular tachycardia. Circulation. 2021;143:212–226.
    1. Gulati A, Jabbour A, Ismail TF, et al. Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy. JAMA. 2013;309:896–908.
    1. Piers SR, Tao Q, van Huls van Taxis CF, Schalij MJ, van der Geest RJ, Zeppenfeld K. Contrast-enhanced MRI–derived scar patterns and associated ventricular tachycardias in nonischemic cardiomyopathy: implications for the ablation strategy. Circ Arrhythm Electrophysiol. 2013;6:875–883.
    1. Di Marco A, Brown PF, Bradley J, et al. Improved risk stratification for ventricular arrhythmias and sudden death in patients with nonischemic dilated cardiomyopathy. J Am Coll Cardiol. 2021;77:2890–2905.
    1. Piers SR, Everaerts K, van der Geest RJ, et al. Myocardial scar predicts monomorphic ventricular tachycardia but not polymorphic ventricular tachycardia or ventricular fibrillation in non-ischemic dilated cardiomyopathy. Heart Rhythm. 2015;12:2106–2114.
    1. Wu KC, Wongvibulsin S, Tao S, et al. Baseline and dynamic risk predictors of appropriate implantable cardioverter defibrillator therapy. J Am Heart Assoc. 2020;9:e017002.
    1. Moss AJ, Schuger C, Beck CA, et al. Reduction in inappropriate therapy and mortality through ICD programming. N Engl J Med. 2012;367:2275–2283.
    1. Pocock SJ, Ariti CA, McMurray JJ, et al. Predicting survival in heart failure: a risk score based on 39 372 patients from 30 studies. Eur Heart J. 2013;34:1404–1413.

Source: PubMed

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