Shunsuke Uetake

BACKGROUND: Radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) in arrhythmogenic right ventricular cardiomyopathy is safe and reduces ventricular arrhythmia burden. Previous studies included adult patients, and data on pediatric patients are scarce. The objective of our study was to report on the safety and efficacy of RFCA in pediatric arrhythmogenic right ventricular cardiomyopathy. METHODS: Fifteen patients who fulfilled the 2010 arrhythmogenic right ventricular cardiomyopathy task force criteria, clinically presented before the age of 18, and underwent VT RFCA procedures at ≤21 years old were included. Baseline characteristics, genotypic and phenotypic data, and ablation outcomes were collected. RESULTS: The mean age at symptom onset was 15.5±1.6 years, and at the index procedure was 18.1±2 years, with 73% of the patients being male. Pathogenic mutation in desmosomal genes was detected in 87%. First presentation symptoms included palpitations (33%), syncope (27%), sustained VT (27%), and sudden cardiac arrest (13%). ECG repolarization abnormalities were present in 93% and 40% were reported to be athletes. In the index RFCA procedure, sustained monomorphic VT was induced in 60%. Electroanatomic mapping showed 100% basal RV epicardial substrate and 54% endocardial low voltage/scar. Repeat VT ablation was required in 80% over a mean follow-up of 16.4 months. The median number of procedures was 2 (interquartile range, 2–4), with sustained VT-free survival of 73% over a mean follow-up duration of 21.4 months. No acute periprocedural complications occurred. Bilateral cardiac sympathetic denervation due to recurrent ventricular arrhythmia was performed in 27%. Eventually, 2 patients (13%) developed advanced heart failure and underwent heart transplantation. CONCLUSIONS: Pediatric arrhythmogenic right ventricular cardiomyopathy RFCA is safe, but early recurrences are common, requiring repeat ablations and sometimes bilateral cardiac sympathetic denervation. The substrate is mostly epicardial with preserved endocardial voltage. VT free survival is 73% after multiple procedures. Progressive heart failure requiring transplantation occurred in 13% within 2 decades of initial presentation.

Introduction: Percutaneous left atrial appendage closure (LAAC) reduces the risk of thromboembolic stroke in patients with non‐valvular atrial fibrillation who cannot tolerate long‐term oral anticoagulation. However, outcomes after LAAC in patients requiring chronic immunosuppressive therapy (IMS) remain unknown. This study aimed to investigate the perioperative and long‐term outcomes of percutaneous LAAC in patients receiving chronic IMS. Methods and Results: Patients who underwent LAAC were retrospectively evaluated according to the presence of long‐term IMS therapy. Perioperative complications, clinical outcomes, and device follow‐up characteristics were evaluated. From November 2017 to March 2023, a total of 1172 patients who underwent LAAC were included (69.3% male, 74.8 years), of whom 74 were taking IMS. The most common reasons for IMS use were rheumatoid arthritis (50.0%), followed by kidney transplantation (17.6%). There were no significant differences in intraoperative complications between the IMS group and the non‐IMS group. (1.4% vs. 1.3%, p = 0.943). During 617 [IQR: 373–1046] days, the incidence of systemic infections was higher in the IMS group (25.0% vs. 6.1%, p < 0.001). There were no significant differences in peri‐device leak (PDL) or device‐related thrombus, but the IMS group had a lower percentage of patients with improvement of PDL during follow‐up (8.3% vs. 50.0%, p = 0.003). Conclusion: Successful LAAC in patients on IMS was achieved without increasing perioperative complications. Patients on chronic IMS did have an increased occurrence of systemic infections during long‐term follow‐up. The presence of IMS use was negatively associated with PDL improvement during follow‐up.

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Background Modification of the low-voltage zone in the left atrium (LA-LVZ) in addition to pulmonary vein isolation (PVI) has not shown sufficient improvement in arrhythmia-free survival in patients with persistent atrial fibrillation (PerAF). Further, the effect of electrical posterior wall isolation (PWI) is controversial. We investigated the impact of existence of LA-LVZ on the outcome of patients undergoing additional PWI for PerAF. Methods A total of 347 patients with PerAF who underwent primary catheter ablation with LA-LVZ based strategy were retrospectively analyzed. Voltage mapping in the left atrium (LA) was performed during sinus rhythm. Additional LVZ ablation was performed in patients with LA-LVZ. The operators decided whether additional PWIs were to be performed. Results Of 347 patients, 108 had LA-LVZ. In the LVZ group, patients with additional PWI (N = 70) had higher rates of freedom from tachyarrhythmia recurrence than those without (77.1% vs. 42.1%, p < 0.001). Furthermore, even when patients were limited to those with LA-LVZ in areas other than the posterior wall (N = 85), PWI had higher success rates (80.9% vs. 42.1%, p < 0.001). In contrast, in patients without LVZ (N = 239), there was no significant difference in the rate of successful outcome between those with and without PWI (81.3% vs. 88.1%, p = 0.112). On the other hand, the patients with PWI had greater atrial tachycardia (AT) recurrence rate than those without PWI (10.0% vs. 2.5%, p = 0.003). Conclusions PWI, in addition to PVI and LVZ modification, may improve single procedural outcomes in patients with PerAF who have LVZ, regardless of the distribution in the LA. A combination of voltage-guided ablation and PWI may be a simple, tailored, and effective ablation strategy.