Catheter Ablation of VT in Normal Hearts

Authors:
Dukkipati SR, Choudry S, Koruth JS, Miller MA, Whang W, Reddy VY.
Citation:
Catheter Ablation of Ventricular Tachycardia in Structurally Normal Hearts: Indications, Strategies, and Outcomes—Part I. J Am Coll Cardiol 2017;70:2909-2923.

The following are key points to remember about this article on catheter ablation of ventricular tachycardia (VT) in structurally normal hearts (part I):

  1. Sustained ventricular tachycardia (VT) is uncommon in patients with structurally normal hearts. Isolated premature ventricular contractions (PVCs) are a more typical manifestation.
  2. The most common site of ventricular arrhythmias (VAs) in patients without structural heart disease is the right or left ventricular outflow tract.
  3. The optimal management strategy for patients with outflow tract PVCs or VT depends on several factors: the presence of symptoms related to the arrhythmia, underlying heart disease, and risk for developing cardiomyopathy.
  4. Pharmacologic therapy with beta-blockers is typically used first-line in patients with symptomatic PVCs. Non-dihydropyridine calcium channel blockers are also an option.
  5. Catheter ablation should be offered to medication-resistant or intolerant patients. Any patient with cardiomyopathy and frequent PVCs (>10%) should be strongly considered for catheter ablation, as LV function typically improves even in the presence of other structural heart disease.
  6. Papillary muscle VAs in the structurally normal heart make up 5-12% of all idiopathic VAs. This arrhythmia commonly presents as PVCs but can also present as nonsustained or sustained VT.
  7. Idiopathic left ventricular VT (ILVT) in the structurally normal heart, also termed fascicular VT, constitutes between 10-20% of all idiopathic VTs.
  8. In the absence of structural heart disease, catheter ablation can be performed for symptomatic and frequent PVCs or ILVT either as first-line treatment or for arrhythmias when refractory to medical therapy.
  9. In the absence of structural heart disease, catheter ablation can be performed for symptomatic and frequent PVCs or idiopathic LV VT either as first-line treatment or for arrhythmias when refractory to medical therapy.
  10. As the risk of subsequent sudden cardiac death is low, implantable cardioverter-defibrillators are not indicated in these individuals except in the rare cases where concomitant polymorphic VT or ventricular fibrillation occurs due to reproducible PVC triggers or when LV dysfunction fails to normalize following catheter ablation.
  11. In patients with structurally normal hearts, the outcomes of catheter ablation are excellent and these patients may be considered for earlier referral for potential curative treatment.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Arrhythmias, Cardiac, Calcium Channel Blockers, Cardiomyopathies, Catheter Ablation, Death, Sudden, Cardiac, Defibrillators, Implantable, Papillary Muscles, Tachycardia, Ventricular, Ventricular Fibrillation, Ventricular Premature Complexes


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