Outcomes of Catheter Ablation of Ventricular Tachycardia in the Setting of Structural Heart Disease

Abstract

Sustained ventricular tachycardias are common in the setting of structural heart disease, either due to prior myocardial infarction or a variety of non-ischemic etiologies, including idiopathic dilated cardiomyopathy, hypertrophic cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy. Over the past two decades, percutaneous catheter ablation has evolved dramatically and has become an effective tool for the control of ventricular arrhythmias. Single and multicenter observational studies as well as several prospective randomized trials have begun to investigate long-term outcomes after catheter ablation procedures. These studies encompass a wide range of mapping and ablation techniques, including conventional activation mapping/entrainment criteria, substrate modification guided by pacemapping, late potential and abnormal electrogram ablation, scar de-channeling, and core isolation. While large-scale, multicenter prospective randomized clinical trials are somewhat limited, the published data demonstrate favorable outcomes with respect to a reduction in overall ventricular tachycardia (VT) burden, reduction of implantable cardioverter defibrillator (ICD) shocks, and discontinuation of anti-arrhythmic medications across varying disease subtypes and convincingly support the use of catheter ablation as the standard of care for many patients with VT in the setting of structural heart disease.

Ablation Outcomes and Predictors of Mortality Following Catheter Ablation for Ventricular Tachycardia: Data From the German Multicenter Ablation Registry

“…This reflects that SHD patients are more likely to have complex substrates, and electrophysiologists are more likely to be limited by procedural factors, such as time, radiofrequency application, and fluoroscopy exposure. 10,28,36,37 Patients with IHD were also less likely to have epicardial disease, which is in line with the predominantly endocardial substrate from coronary artery stenosis/occlusion. [38][39][40] However, they are more likely to receive substrate modification/linear ablation, and had more ablation success.…”

“…In fact, right ventricular outflow tract VT can follow a benign course . In patients with SHD, the underlying pathologies such as IHD, valvular heart disease, and cardiomyopathies lead to a much more complex substrate . These patients are more likely to have cardiovascular risk factors, are often more unstable, have more incessant arrhythmias, and are less likely to be responsive to AADs .…”

“…25 In patients with SHD, the underlying pathologies such as IHD, valvular heart disease, and cardiomyopathies lead to a much more complex substrate. [26][27][28] These patients are more likely to have cardiovascular risk factors, are often more unstable, have more incessant arrhythmias, and are less likely to be responsive to AADs. 29,30 It was also seen in this registry that these patients predominantly had VTs with origins in the LV.…”

Extracorporeal life support for refractory ventricular tachycardia

“…Catheter guided ablation is a valuable option in abolishing VT (13,14). Radiofrequency ablation should be considered in patients with a history of syncope, very fast VT (ventricular rate >230 beats per minute), and extremely frequent ectopy (>20,000 extrasystoles per day), which may lead to premature ventricular contraction induced cardiomyopathy (5,15,16).…”

“…Radiofrequency ablation should be considered in patients with a history of syncope, very fast VT (ventricular rate >230 beats per minute), and extremely frequent ectopy (>20,000 extrasystoles per day), which may lead to premature ventricular contraction induced cardiomyopathy (5,15,16). Catheter ablation may not abolish VT in a single procedure; however, an ablation procedure may reduce VT burden, reduce ICD shocks, and may allow reduction or discontinuation of antiarrhythmic medication (14). A wide range of mapping and ablation techniques have been described.…”