Article Impact Level: HIGH Data Quality: STRONG Summary of Circulation, CIRCULATIONAHA.122.063367. https://doi.org/10.1161/CIRCULATIONAHA.122.063367 Dr. Koonlawee Nademanee et al.
Points
- Brugada syndrome (BrS) is a rare genetic disorder that increases the risk of sudden cardiac death due to recurrent ventricular fibrillation (VF).
- Current treatment options for high-risk BrS patients with recurrent VF are limited, but catheter ablation is becoming increasingly popular as a treatment option.
- The BRAVO study enrolled 159 patients with high-risk symptomatic BrS and spontaneous VF and found that ablation treatment is safe and highly effective in preventing VF recurrence.
- After a single ablation procedure, 81% of patients remained VF recurrence-free. This number increased to 96% after a repeated procedure with a mean follow-up period of 48±29 months from the last ablation.
- The only variable associated with a VF-free outcome in the multivariable analysis was the normalization of the type 1 Brugada ECG after 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).
Summary
The Brugada syndrome (BrS) is a rare genetic disorder that increases the risk of sudden cardiac death due to recurrent ventricular fibrillation (VF). Current treatment options for high-risk BrS patients with recurrent VF are limited. However, catheter ablation is becoming increasingly popular as a treatment option, and a large-scale study with long-term outcome data is lacking. To address this, the multicenter, international BRAVO (Brugada Ablation of VF Substrate Ongoing Registry) study was conducted to investigate the efficacy and safety of percutaneous epicardial substrate ablation with electroanatomical mapping.
The BRAVO study enrolled 159 patients with high-risk symptomatic BrS and spontaneous VF. Of these patients, 43 (27%) had BrS and early repolarization patterns, and all but 5 had an implantable cardioverter-defibrillator for cardiac arrest or syncope. 140 (88%) had experienced numerous implantable cardioverter-defibrillator shocks for spontaneous VF before ablation. 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 had a substrate in the posterior left ventricular epicardium.
After a single ablation procedure, 81% of patients remained VF recurrence-free. This number increased to 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. The Kaplan-Meier VF-free survival beyond five (5) years after the last ablation was 95%. The only variable associated with a VF-free outcome in the multivariable analysis was the normalization of the type 1 Brugada ECG after 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 study concluded that ablation treatment is safe and highly effective in preventing VF recurrence in high-risk BrS patients. There were no arrhythmic or cardiac deaths, and complications included hemopericardium in 4 (2.5%) patients. The BRAVO study provides valuable long-term outcome data on the efficacy and safety of percutaneous epicardial substrate ablation for high-risk BrS patients with recurrent VF. This information can inform clinical decision-making and improve patient outcomes. Prospective studies are needed to determine whether it can be an alternative treatment to implantable cardioverter-defibrillator implantation for selected patients with BrS.
Link to the article: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.063367
References Nademanee, K., Chung, F.-P., Sacher, F., Nogami, A., Nakagawa, H., Jiang, C., Hocini, M., Behr, E., Veerakul, G., Jan Smit, J., Wilde, A. A. M., Chen, S.-A., Yamashiro, K., Sakamoto, Y., Morishima, I., Das, M. K., Khongphatthanayothin, A., Vardhanabhuti, S., & Haissaguerre, M. (2023). Long-term outcomes of brugada substrate ablation: A report from bravo(Brugada ablation of vf substrate ongoing multicenter registry). Circulation, CIRCULATIONAHA.122.063367. https://doi.org/10.1161/CIRCULATIONAHA.122.063367
