Catheter Ablation of VT in Structural Heart Disease

Dukkipati SR, Koruth JS, Choudry S, Miller MA, Whang W, Reddy VY.
Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: Indications, Strategies, and Outcomes—Part II. J Am Coll Cardiol 2017;70:2924-2941.

The following are key points to remember about this article on catheter ablation of ventricular tachycardia (VT) in structural heart disease (part II):

  1. In contrast to VT that occurs in the setting of a structurally normal heart, VT that occurs in patients with structural heart disease carries an elevated risk for sudden cardiac death (SCD), and implantable cardioverter-defibrillators (ICDs) are the mainstay of therapy.
  2. Beta-blockers, if not contraindicated, are recommended, as they decrease mortality following VT/ventricular fibrillation (VF) and in patients with heart failure and reduced left ventricular (LV) function.
  3. Catheter ablation may be used as adjunctive therapy to treat or prevent repetitive ICD therapies when antiarrhythmic drugs are ineffective or not desired.
  4. Catheter ablation would be indicated specifically for patients with sustained monomorphic VT that recurs despite antiarrhythmic drugs or when drugs are not tolerated or desired, control of incessant sustained monomorphic VT or VT storm that is not due to a transient reversible cause, bundle branch reentrant or interfascicular VT, frequent premature ventricular contractions (PVCs), nonsustained or sustained VT in the setting of ventricular dysfunction and recurrent sustained polymorphic VT, and VF that is refractory to antiarrhythmic therapy and thought to be secondary to a trigger that is amenable for ablation.
  5. Additionally, catheter ablation may be considered for sustained monomorphic VT despite therapy with class I/III antiarrhythmic drugs, as an alternative to amiodarone in patients with prior myocardial infarction (MI) and LV ejection fraction (LVEF) >30%, and as an alternative to antiarrhythmic drugs for hemodynamically tolerated sustained monomorphic VT due to prior MI and LVEF >35%.
  6. In certain patients with frequent PVCs or VT and tachycardiomyopathy, ablation may be considered prior to ICD implantation as LV function may improve, consequently decreasing the risk of SCD and obviating the need for an ICD.
  7. The general approach to catheter ablation of VT in structural heart disease involves the characterization of target VTs, delineation of the arrhythmic substrate, and radiofrequency ablation of the arrhythmic tissue.
  8. Catheter ablation of VT in patients with structural heart disease can significantly reduce the incidence of recurrent ventricular arrhythmias.
  9. Overall, catheter ablation in this population has an acceptable risk, but patients presenting with VT storm, advanced heart failure with severely reduced LV function, and certain other comorbidities are at increased risk for procedure-related hemodynamic decompensation; they may benefit from percutaneous hemodynamic support during the procedure.
  10. Technological advancements in substrate imaging, mapping, and ablation will further improve outcomes after ablation.

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

Keywords: Adrenergic beta-Antagonists, Amiodarone, Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Catheter Ablation, Comorbidity, Death, Sudden, Cardiac, Defibrillators, Implantable, Heart Failure, Myocardial Infarction, Secondary Prevention, Tachycardia, Ventricular, Ventricular Fibrillation, Ventricular Premature Complexes

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