Skip to Main Content

Chapter 18: Catheter Ablation of Ventricular Tachyarrhythmias

James P. Daubert

INTRODUCTION

General Features of Ventricular Tachycardia Ablation Patients

Patients undergoing ablation for ventricular arrhythmias have somewhat of a bimodal distribution, including those with severe structural heart disease versus other patients with idiopathic ventricular tachycardia (VT) having a structurally normal heart. First, characteristics of the structural heart VT patients include: (1) a very high medical acuity with most being inpatient and often in an intensive care unit (ICU); (2) frequent need for urgent ablation; (3) severe structural heart disease due to 1 or more prior, often large, myocardial infarctions (MIs), or severe nonischemic cardiomyopathy (NICM); (4) most have been implanted with ICDs; (5) many have had cardiac arrest and/or VT or VF storm (≥3 episodes within 24 hours) having received multiple shocks; (6) many are being managed with intravenous antiarrhythmics; (7) consideration for hemodynamic support (intra-aortic balloon pump, percutaneous left ventricular assist device, or extracorporeal membrane oxygenation) is common. On the other hand, a substantial number of VT ablation patients1 have idiopathic ventricular arrhythmias, lacking appreciable structural heart disease. The relative distribution will depend on referral patterns. Origins include the outflow tract region, the conduction system, and papillary muscles. Sustained VT occurs with these foci, but many have PVCs or nonsustained VT.

Indications for Ventricular Arrhythmia Ablation

In general, ventricular arrhythmia ablation is indicated when medical therapy has failed or is not tolerated or not preferred by the patient (Table 18-1). Medical treatment for sustained reentrant VT with dilated (ischemic or nonischemic) cardiomyopathy includes amiodarone or possibly sotalol (if the heart failure or EF depression is not severe). For normal heart ventricular arrhythmia, medical options comprise beta blockers, nondihydropyridine calcium channel blockers, or Class I or III antiarrhythmic agents. Verapamil can be uniquely effective for fascicular VT (see Chapter 8).

TABLE 18-1Indications for ventricular arrhythmia ablation.
View Table||Download (.pdf)
TABLE 18-1 Indications for ventricular arrhythmia ablation.

Ventricular Arrhythmia

Class of Indication

Sustained monomorphic VT (post-infarct); failure of amiodarone or sotalol; frequent VT or VT storm

I

Sustained monomorphic VT (post-infarct); failure of amiodarone or sotalol; single or occasional episodes

IIA

Sustained monomorphic VT (NICM); failure of amiodarone or sotalol

IIA

Polymorphic VT/VF; no reversible cause; not controlled with medications; identifiable PVC triggers

I

RVOT/LVOT PVCs or VT; normal heart; antiarrhythmic medications ineffective, not tolerated, or not preferred

I

RVOT/LVOT PVCs or VT; with suspected PVC cardiomyopathy (usually >15% PVCs); antiarrhythmic medications ineffective, not tolerated, or not preferred

I

Fascicular VT; antiarrhythmic medications ineffective, not tolerated, or not preferred

I

Papillary muscle PVCs or VT; antiarrhythmic medications ineffective, not tolerated, or not preferred

I

(Note: Guidelines from Al-Khatib SM, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close