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Ventricular tachycardia in ischaemic heart disease. Update on electrical therapy

ESC Congress 2010

Arrhythmias and Device Therapy

The first speaker, Dr. J. Brugada, from Barcelona (Spain), spoke about management of ventricular tachycardia storms. After recognizing that electrical storm is relatively frequent among ICD patients, he emphasized that there is a variety of therapeutic options, including drugs and catheter ablation. However, when asked how frequently ablation should be used, he agreed that, after a brief initial attempt at pharmacologic control, close to 100% of patients will require ablation.

In my opinion, it is unfortunate that many centres keep trying different pharmacologic regimens and refer patients to ablation too late, after clinical deterioration, when the risk of the ablation procedure is higher and the benefit lower. Personal data about success with epicardial ablation was offered: it was successful in 21 out of 23 patients with electrical storm in whom endocardial ablation was unsuccessful.

Dr. J Atie, from Rio de Janeiro (Brazil) dealt with the role of epicardial ventricular tachycardia mapping and ablation. The epicardial origin of a VT can be suggested either by a detailed analysis of the 12-lead ECG or by imaging techniques such as magnetic resonance. Although usually an epicardial approach is reserved to cases in which an endocardial approach has failed, in cases with a likely epicardial origin, an alternative approach is to begin with pericardial access, leaving a guide wire, and then proceed with the endocardial procedure with anticoagulation, so epicardial ablation can be attempted later if necessary without stopping anticoagulation.

This approach is presently recommended in patients with idiopathic dilated cardiomyopathy, inferior myocardial infarction and hypertrophic cardiomyopathy when the ECG of the VT suggests an epicardial origin. In patients with arrhythmogenic right ventricular cardiomyopathy, an epicardial approach can almost always be advocated.

The difficult task of assessing in which patients catheter ablation can be an alternative to the implantation of an ICD was covered by Dr. K Zeppenfeld from Leiden (The Netherlands). After recognizing that we have evidence that ICD can prolong life in several patient groups (and such evidence has never been tested for catheter ablation), she reviewed the limitations of ICD therapy, including frequent device-related complications, data suggesting that ICD shocks are harmful and may increase mortality, and subgroup analysis identifying patients without ICD benefit.

It has to be realized that no ICD trial included patients with tolerated sustained VT. Catheter ablation has been shown to prevent VT recurrence and decrease ICD shocks in randomized controlled trials, so it seems an attractive option for VT patients. The bulk of information suggests that catheter ablation can be an alternative to ICD therapy in patients without a severe depression of left ventricular function, and in certain patients with tolerated VT and severe ventricular dysfunction, when no additional risk factors for sudden death are present.

The role of prophylactic catheter ablation was the task of Dr. P. Notarstefano, from Arezzo (Italy). Prophylactic catheter ablation was considered when the procedure was performed at the time of ICD indication as opposed to after ICD therapies (although the use of the term “prophylactic” is not totally appropriate in this context). Recently, two randomized controlled trials (SMASH-VT and V-TACH) have analyzed the effects of such an approach, both showing a decrease in ICD therapies in the ablation group as compared to no ablation. However, the magnitude of the difference in the V-TACH trial was not as impressive as in the SMASH-VT trial. No mortality difference was observed, but the trials were not powered to detect a mortality difference.
We can conclude that more data are necessary in terms of hospitalization and/or quality of life, before a general recommendation can be made in favour of catheter ablation at the time of ICD indication.




Ventricular tachycardia in ischaemic heart disease. Update on electrical therapy
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.