Recently, an expert consensus statement proposed indications where implantation of a primary prevention implantable cardioverter-defibrillator (ICD) may be reasonable in patients with mitral valve prolapse (MVP). The objective was to evaluate the proposed risk stratification by the expert consensus statement.
Consecutive patients with MVP without alternative arrhythmic substrates with cardiac magnetic resonance imaging (CMR) were included in a single-center retrospective registry. Arrhythmic MVP (AMVP) was defined as a total premature ventricular complex burden ≥5%, non-sustained ventricular tachycardia (VT), VT, or ventricular fibrillation. The end point was a composite of SCD, VT, inducible VT, and appropriate ICD shocks.
In total, 169 patients (52.1% male, median age 51.4 years) were included and 99 (58.6%) were classified as AMVP. Multivariate logistic regression identified the presence of late gadolinium enhancement (OR 2.82, 95%CI 1.45-5.50) and mitral annular disjunction (OR 1.98, 95%CI 1.02-3.86) as only predictors of AMVP. According to the EHRA risk stratification, 5 patients with AMVP (5.1%) had a secondary prevention ICD indication, while in 69 patients (69.7%) the implantation of an ICD may be reasonable. During a median follow-up of 8.0 years (IQR 5.0-15.6), the incidence rate for the composite arrhythmic end point was 0.3%/year (95%CI 0.1-0.8).
More than half of MVP patients referred for CMR met the AMVP diagnostic criteria. Despite low long-term event rates, in 70% of patients with AMVP the implantation of an ICD may be reasonable. Risk stratification of SCD in MVP remains an important knowledge gap and requires urgent investigation.

The recent 2022 European Society of Cardiology Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death are an update of the former 2015 European guidelines. With multiple tables, algorithms, and comprehensive integration of underlying study data, the new guideline is a user-oriented reference book for clinical practice that also covers special clinical situations such as cardiac arrhythmias in pregnancy or in the context of sports. Regarding the acute treatment of ventricular arrhythmias, cardioversion is now recommended in case of hemodynamically tolerated arrhythmias. Beyond that, the guideline places special emphasis on the management of the electrical storm. In long-term therapy, recommendations for drug therapy have been aligned with current heart failure guidelines. Catheter ablation of ventricular arrhythmias has gained importance not only for recurrent ventricular tachycardia under chronic amiodarone therapy and as an alternative to implantable cardioverter-defibrillators (ICDs) in selected patients with coronary artery disease, but especially for the treatment of idiopathic premature ventricular contractions and tachycardias. Risk stratification and criteria for primary preventive ICDs are still controversial topics, which are discussed in detail based on the specific disease entities.
UNASSIGNED: Die aktuelle Leitlinie der europäischen Gesellschaft für Kardiologie 2022 zum Management von Patienten mit ventrikulären Arrhythmien und zur Prävention des plötzlichen Herztods aktualisiert die Leitlinie aus dem Jahr 2015. Mit zahlreichen Übersichtstabellen, Algorithmen und einer umfangreichen Einbeziehung der zugrundeliegenden Studiendaten liegt ein anwenderbezogenes Nachschlagewerk für die klinische Praxis vor, das auch besondere klinische Situationen wie Herzrhythmusstörungen in der Schwangerschaft oder im Zusammenhang mit Sport umfasst. In der Akuttherapie ventrikulärer Arrhythmien ist die Kardioversion auch bei hämodynamisch tolerierter Arrhythmie aufgewertet, zudem liegt ein besonderer Schwerpunkt der Leitlinie auf dem Management des elektrischen Sturms. In der Langzeittherapie sind die Empfehlungen zur medikamentösen Therapie an aktuelle Herzinsuffizienzleitlinien angeglichen. Katheterinterventionelle Verfahren gewinnen nicht nur bei rezidivierenden ventrikulären Tachykardien unter Amiodarontherapie und als Alternative zur ICD-Implantation bei ausgewählten Patienten mit koronarer Herzerkrankung, sondern insbesondere bei der Behandlung idiopathischer ventrikulärer Extrasystolen und Tachykardien an Bedeutung. Die Risikostratifikation bzw. Kriterien zur primärprophylaktischen ICD-Implantation sind unverändert kontroverse Themen, die in der aktuellen Leitlinie anhand der spezifischen Krankheitsbilder ausführlich diskutiert werden.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

OBJECTIVE: To determine criteria for choosing management tactics in patients with ventricular arrhythmias (VA) in the absence of structural heart disease from the point of view of physicians and patients in clinical practice and to compare the immediate results of antiarrhythmic drug therapy (ADT) and radiofrequency ablation (RFA) with the trends in arrhythmic syndrome in the non-treatment group.
METHODS: Examinations were made in 90 patients (23 men and 67 women) (mean age, 44 (31; 57) years) with VA in the absence of structural heart disease. Preference was given to RFA (n = 32 (36%)), ADT (n = 37 (41%)), and follow-up tactics (n = 21 (23%)). At baseline and 1 month, Holter ECG monitoring was done; quality of life (QOL) was assessed; and anxiety and depression levels were detected using the SF-36 and HADS questionnaires. In addition, 71 physicians were surveyed about their preferences to the treatment of VA in individuals without structural heart disease.
RESULTS: In the total group of patients, VA was unambiguously accompanied by the symptoms only in 47%. The signs of anxiety and depression were identified in 41 and 14% of cases, respectively. The efficiency of RFA was comparable to that of ADT (p > 0.1): a positive antiarrhythmic effect was observed in 71.9% of the patients in the RFA group and in 67.6% in the ADT group. During one month, 38.1% of the patients in the follow-up group showed a spontaneous substantial reduction in the number of ventricular premature beats (VPBs) or disappearance of unstable ventricular tachycardia (UVT), which met the criteria for a positive effect. At baseline, the QOL indicators on a social functioning scale in the RFA group were worse than those in the ADT group. At the same time, most QOL indicators in the patients who have chosen a wait-and-see tactic were significantly higher than those in the RFA and ADT subgroups. The patients treated with ethacyzin in the ADT group more frequently achieved a positive effect. In the interviewed physicians\' opinion, the choice of a tactic depended on the impact of arrhythmia on health status (68%), the number of VPBs per day (61%), and the presence of UVT (56%). RFA or ADT was most often recommended when there were 10,000-15,000 or more VPBs per day ((49 and 35% of the respondents, respectively). 46.5% of the respondents stated that β-blockers were the drug of choice for idiopathic frequent VPBs. Only 30% of the respondents considered it appropriate to restrict to a follow-up in the presence of asymptomatic VPBs.
CONCLUSIONS: Patient management in clinical practice generally complies with the current guidelines; however, much importance is attached to the severity of arrhythmia (the number of VPBs per day, the presence of UVT) in addition to the presence of symptoms. In the opinion of most physicians, the initiation of treatment is justified when there are 10,000-15,000 and more per day. QOL assessment may be promising in choosing the optimal management tactics for these patients. Treatment should not be initiated immediately in patients with a high level of QOL, especially in those with arrhythmia lasting less than 12 months, by taking into account that there can be a spontaneous improvement in 38% of cases within the next month. The immediate results of ADT and RFA are comparable in patients with VA in the absence of structural heart disease. The Class IC antiarrhythmic drug ethacyzin is the most effective agent that ensures positive changes in arrhythmic syndrome in 66.7% of cases with the rate of side effects being in 17.8%.
Цель исследования. Определение критериев выбора тактики ведения больных с желудочковыми нарушениями ритма (ЖНР) в отсутствие структурной патологии сердца с точки зрения врачей и пациентов в клинической практике и сравнение ближайших результатов медикаментозной антиаритмической терапии (ААТ), радиочастотной абляции (РЧА) с динамикой аритмического синдрома в группе без лечения. Материалы и методы. Обследовали 90 пациентов (23 мужчины и 67 женщин, средний возраст 44 (31; 57) года) с желудочковыми аритмиями (ЖА) в отсутствие структурной патологии сердца. РЧА предпочли 32 (36%) пациента, ААТ - 37 (41%), тактику динамического наблюдения - 21 (23%). Исходно и через 1 мес выполняли холтеровское мониторирование электрокардиограммы, оценку качества жизни (КЖ) и определяли уровни тревоги и депрессии с помощью опросников SF-36 и HADS. Кроме того, проводили опрос 71 врача о предпочтениях в лечении ЖНР у лиц без структурной патологии сердца. Результаты. В общей группе пациентов лишь у 47% ЖА однозначно сопровождались симптомами. Признаки тревоги выявлены в 41% случаев, депрессии - в 14%. По эффективности РЧА и ААТ оказались сопоставимы (p>0,1): положительный антиаритмический эффект отмечен у 71,9% пациентов в группе РЧА и у 67,6% группы ААТ. У 38,1% больных группы наблюдения в течение 1 мес отмечалось спонтанное существенное сокращение числа желудочковых экстрасистолий (ЖЭ) или исчезновение неустойчивой желудочковой тахикардии (НУЖТ), соответствующее критериям положительного эффекта. Исходно лишь по шкале социального функционирования показатели КЖ в группе РЧА были хуже, чем в группе ААТ. В то же время большинство показателей КЖ у лиц, избравших выжидательную тактику, было достоверно выше, чем у пациентов из групп РЧА и ААТ. В группе ААТ чаще всего положительный эффект достигался на фоне приема этацизина. По мнению опрошенных врачей, выбор тактики зависит от влияния аритмии на самочувствие (68%), количества ЖЭ за сутки (61%), наличия НУЖТ (56%). Наиболее часто проведение РЧА или ААТ рекомендовали при количестве ЖЭ 10 000-15 000 в сутки и более (49 и 35% респондентов соответственно). В качестве препарата выбора при идиопатической частой ЖЭ 46,5% опрошенных отметили β-адреноблокаторы. При бессимптомной ЖЭ лишь 30% респондентов считают целесообразным ограничиться динамическим наблюдением. Заключение. Ведение пациентов в клинической практике в целом соответствует действующим рекомендациям, однако помимо \'симптомности\' большое значение уделяется выраженности аритмии (число ЖЭ в сутки, наличие НУЖТ). По мнению большинства врачей, начало лечения обосновано при суточном количестве ЖЭ 10 000-15 000 и более. Оценка КЖ может быть перспективной для выбора оптимальной тактики ведения таких больных. Пациентам с высоким уровнем КЖ, особенно при давности возникновения аритмии менее 12 мес, немедленное начало лечения не показано, учитывая возможность спонтанного улучшения в 38% случаев в течение ближайшего месяца. У пациентов с ЖА в отсутствие структурной патологии сердца ближайшие результаты ААТ и РЧА сопоставимы. Антиаритмический препарат IС класса этацизин в данной группе пациентов является наиболее эффективным антиаритмическим препаратом, обеспечивающим положительную динамику аритмического синдрома в 66,7% случаев при частоте побочных эффектов 17,8%.

暂无摘要。

Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome.
Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms.
Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function.
Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63-8.66; P=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67-0.83; P<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65-0.79; P<0.0001), and a second \"minimal overlap\" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61-0.82; P<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60-0.85; P<0.001).

暂无摘要。