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Refractory ventricular tachycardias and electrical storm

Rapidly recurrent ventricular arrhythmia is not an infrequent clinical entity in the era of implantable cardioverter defibrillator therapy. Electrical storm appears to be a harbinger of cardiac death with a notably high mortality early post arrhythmic event.

Arrhythmias


Management of electrical storm in ischaemic heart disease

J P Amlie (Oslo, NO) highlighted that in ischaemic heart disease, the mechanism of ventricular tachycardia (VT) is mainly a reentry circuit. There are two types of VT (monomorphic and polymorphic). Polymorphic VT are often associated with ischemic events. Ventricular dispersion >90ms is associated with a high risk of this type of VT. Monomorphic VT may be treated by catheter ablation. Pharmacological treatment of VT may include flecainide if necessary. He concludes that coronarography is useful leading to revascularization in many cases. Whenever radiofrequency ablation is unsuccessful, surgery and cardiac transplantation may be indicated.

Management of electrical storm in idiopathic dilated cardiomyopathy

C Carbucicchio (Milano, IT) showed the large experience of his group. He differentiated ischemic VT from idiopathic since the first is related to a more localized and homogeneous scar. He indicated that one third of patients need an epicardial approach with 43% of them performed on the first ablation procedure. The aim of the treatment is to destroy mid-diastolic potentials after an accurate mapping to stabilize the scar and interrupt the slow pathways. The acute success is high (89% after one to three procedures), and associated to low VT recurrence. The ICD discharges are reduced as well as cardiac mortality.

Surgical therapy for refractory ventricular tachycardia

K Zeppenfeld (Leiden, NL) reviewed the importance of endocardial incisions and left ventricular restoration surgery to treat refractory VT. The mortality associated to the procedure is inferior to 10%. In her center, 5% of all VT ablation patients are referred to surgery. Whenever percutaneous epicardial approach is difficult, a surgical subxiphoid window may be performed allowing successful ablation. Surgical VT ablation may be a primary option if the patient is submitted to other cardiac surgery. In this case, prior percutaneous endocardial mapping may be necessary.

Conclusion:

In VT storm patients, the challenge for cardiovascular practitioners is to maximize substrate-based therapy not only to prevent further episodes of electrical storm, but possibly also to reduce the considerable risk of subsequent cardiac mortality.

References


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SessionTitle:

Refractory ventricular tachycardias and electrical storm

Notes to editor


This congress report accompanies a presentation given at the ESC Congress 2009. Written by the author himself/herself, this report does not necessarily reflect the opinion of the European Society of Cardiology.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.