EHRA Key References on Ventricular arrhythmias

Structural ventricular tachycardias

Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA).
Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Della Bella P, Hindricks G, Jaïs P, Josephson ME, Kautzner J, Kay GN, Kuck KH,Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D;
European Heart Rhythm Association (EHRA); Registered Branch of the European
Society of Cardiology (ESC); Heart Rhythm Society (HRS); American College of
Cardiology (ACC); American Heart Association (AHA). EHRA/HRS
Heart Rhythm. 2009 Jun;6(6):886-933

Venice Chart International Consensus document on ventricular tachycardia/ventricular
fibrillation ablation.
Natale A, Raviele A, Al-Ahmad A, Alfieri O, Aliot E, Almendral J, Breithardt
G, Brugada J, Calkins H, Callans D, Cappato R, Camm JA, Della Bella P, Guiraudon
GM, Haïssaguerre M, Hindricks G, Ho SY, Kuck KH, Marchlinski F, Packer DL,
Prystowsky EN, Reddy VY, Ruskin JN, Scanavacca M, Shivkumar K, Soejima K,
Stevenson WJ, Themistoclakis S, Verma A, Wilber D; Venice Chart members.
J Cardiovasc Electrophysiol. 2010 Mar;21(3):339-79.

Electrophysiologic substrate underlying postinfarction ventricular tachycardia: characterization and role in catheter ablation.
Haqqani HM, Marchlinski FE.
Heart Rhythm. 2009 Aug;6(8 Suppl):S70-6

This review examines the role that the electrophysiologic substrate plays in the mechanism of scar-related VT and how this substrate is mapped, defined, and ablated.

ECG criteria to identify epicardial ventricular tachycardia in nonischemic cardiomyopathy.
Vallès E, Bazan V, Marchlinski FE.
Circ Arrhythm Electrophysiol. 2010 Feb;3(1):63-71.

ECG criteria identifying epicardial origin for ventricular tachycardia in nonischemic cardiomyopathy have not been determined. Endocardial and epicardial basal left ventricle fibrosis characterizes the VT substrate. Morphological ECG features that describe the initial QRS vector can help identify basal-superior/lateral epicardial VTs in nonischemic cardiomyopathy.


Relationship of late potentials to the ventricular tachycardia circuit defined by entrainment.
Hsia HH, Lin D, Sauer WH, Callans DJ, Marchlinski FE.
J Interv Card Electrophysiol. 2009 Oct;26(1):21-9

Findings of this educational study  have important implications in substrate-based ablation strategies targeting LPs. Electrograms near the VT circuit isthmus have a higher incidence of late potentials (LP) compared to that of entrance and exit; and the QRS-LP interval is significantly longer near entrance and isthmus compared to exit sites.


Endocardial unipolar voltage mapping to detect epicardial ventricular tachycardia substrate in patients with nonischemic left ventricular cardiomyopathy.
Hutchinson MD, Gerstenfeld EP, Desjardins B, Bala R, Riley MP, Garcia FC,
Dixit S, Lin D, Tzou WS, Cooper JM, Verdino RJ, Callans DJ, Marchlinski FE.
Circ Arrhythm Electrophysiol. 2011 Feb;4(1):49-55.

Epicardial arrhythmia substrate can be reliably identified in most patients with left ventricular cardiomyopathy using endocardial unipolar voltage mapping in the absence of  endocardial bipolar abnormalities.

Endocardial and epicardial mapping and catheter ablation of post myocardial infarction ventricular tachycardia: A substrate modification approach.  
Arruda M, Fahmy T, Armaganijan L, Di Biase L, Patel D, Natale A.
J Interv Card Electrophysiol. 2010 Aug;28(2):137-45

Three-dimensional mapping systems have allowed identification of the scar substrate, its critical sites in the tachycardia circuit, and selection of ablation sites based on fairly precise electroanatomic substrate.

Catheter ablation of ventricular tachycardia in ischaemic and non-ischaemic cardiomyopathy: where are we today? A clinical review.
Wissner E, Stevenson WG, Kuck KH.
Eur Heart J. 2012 Jun;33(12):1440-50

This review highlights the recent progress made in the ablative treatment of VT in patients with ischemic and non-ischemic cardiomyopathy.

Epicardial ventricular tachycardia ablation a multicenter safety study.
Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, Hocini M,Koplan B, Leroux L, Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG.
J Am Coll Cardiol. 2010 May 25;55(21):2366-72.

Summarizing the results of this important study: VT ablation required epicardial ablation in 121 of 913 procedures (13%), with a risk of 5% and 2% of acute and delayed major complications related to epicardial access.

Epicardial ablation for ventricular tachycardia: a European multicenter study.
Della Bella P, Brugada J, Zeppenfeld K, Merino J, Neuzil P, Maury P,Maccabelli G, Vergara P, Baratto F, Berruezo A, Wijnmaalen AP.
Circ Arrhythm Electrophysiol. 2011 Oct;4(5):653-9.

In experienced centers, epicardial ablation of VT has an acceptable risk and favorable outcome. In selected patients, it is reasonable to consider as a first-line ablation approach.
 
Modification in Patients With Scar-Related Ventricular Tachycardia Elimination of Local Abnormal Ventricular Activities : A New End Point for Substrate.
Jaïs et al. Circulation. 2012;125:2184-2196.

A total of 75 patients with structurally abnormal hearts and ventricular tachycardia underwent radiofrequencay ablation  (via either endocardial or epicardial access) of local abnormal ventricular activities (LAVAs) during sinus rhythm or ventricular pacing. LAVAs
were successfully abolished or dissociated in 47 of 67 patients (70%). In multivariate analysis, LAVA elimination was independently associated with a reduction in recurrent VT or death (hazard ratio, 0.49; 95% confidence interval, 0.26–0.95; P=0.035) during a median 22 months’ follow-up.

Outcomes of catheter ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia/cardiomyopathy.
Philips B, Madhavan S, James C, Tichnell C, Murray B, Dalal D, Bhonsale A,
Nazarian S, Judge DP, Russell SD, Abraham T, Calkins H, Tandri H.
Circ Arrhythm Electrophysiol. 2012 Jun 1;5(3):499-505.
 
Although VT recurrences are common, RFA results in a significant reduction in the burden of VT in patients with ARVD/C. Further, although the use of 3D electroanatomic mapping systems and epicardial ablation strategies are associated with longer survival free of VT, recurrence rates remain considerable.

Lack of uniform progression of endocardial scar in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy and ventricular tachycardia.
Riley MP, Zado E, Bala R, Callans DJ, Cooper J, Dixit S, Garcia F, Gerstenfeld
EP, Hutchinson MD, Lin D, Patel V, Verdino R, Marchlinski FE.
Circ Arrhythm Electrophysiol. 2010 Aug;3(4):332-8.

In patients with ARVD/C and ventricular tachycardia, progressive RV dilatation is the rule, and rapid progression of significant macroscopic endocardial scar occurs in only a subset of patients. These results have important management implications, suggesting that efforts to prevent RV dilatation in this population are needed and that an aggressive substrate-based ablation strategy offers the potential to provide long-term ventricular tachycardia control.

Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients withcoronary heart disease (VTACH): a multicentre randomised controlled trial.
Kuck KH, Schaumann A, Eckardt L, Willems S, Ventura R, Delacrétaz E, Pitschner
HF, Kautzner J, Schumacher B, Hansen PS; VTACH study group.
Lancet. 2010 Jan 2;375(9708):31-40.

Prophylactic VT ablation before defibrillator implantation seemed to prolong time to recurrence of VT in patients with stable VT, previous myocardial infarction, and reduced LVEF. Prophylactic catheter ablation should therefore be considered before implantation of a cardioverter defibrillator in such patients.

Idiopathic ventricular arrhythmias

Ablation is idiopathic polymorphic ventricular tachycardias or ventricular fibrillation

Role of Purkinje conducting system in triggering of idiopathic ventricular fibrillation.
Haissaguerre M, Shah DC, Jais P, Shoda M, Kautzner J, Arentz T, Kalushe D, Kadish A, Griffith M, Gaita F, Yamane T, Garrigue S, Hocini M, Clementy J.
Lancet. 2002 23;359(9307):677-8.

This is the first publication describing the mapping and ablation of short coupled VPC triggers of idiopathic VF. This is also the source publication establishing the Purkinje fibres as the dominant source of short coupled VPCs triggering VF.

Short-coupled variante of torsade de pointes. A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias.
 Leenhardt A, Glaser E, Burguera M, Nurnberg N, Maison-Blanche P, Coumel P. Circulation 1994, 89:206-215.
This study describes the first series of short coupled VPCs triggering Torsades des pointes and arrhythmogenic sudden death in the absence of heart disease. Drug treatment with Verapamil and ICD implantation were used for these patients before ablation was proposed.

Long-term follow-up of idiopathic ventricular fibrillation ablation: a multicenter study.
Knecht S, Sacher F, Wright M, Hocini M, Nogami A, Arentz T, Petit B, Franck R, De Chillou C, Lamaison D, Farré J, Lavergne T, Verbeet T, Nault I, Matsuo S, Leroux L, Weerasooriya R, Cauchemez B, Lellouche N, Derval N, Narayan SM, Jaïs P, Clementy J, Haïssaguerre M.  J Am Coll Cardiol. 2009 Aug 4;54(6):522-8.

This study describes the long term follow up of patients who underwent triggering VPC ablation.

Ablation of  sustained idiopathic ventricular tachycardias


Correlative anatomy for the invasive electrophysiologist: outflow tract and supravalvular arrhythmia.
Asirvatham SJ: J Cardiovasc Electrophysiol 2009;20:955-968

Ablation above the semilunar valves: when, why, and how? Part I.
Suleiman M, Asirvatham SJ.
Heart Rhythm. 2008 Oct;5(10):1485-92
Great review about the anatomy of the right ventricular outflow tract and its adjacent structures (including the aortic cusps). The anatomy is correlated to electrical signals recorded during ventricular arrhythmia from this area. Very helpful for electrophysiologists to identify the correct ablation sites in the right ventricular outflow tract and the aortic root.

Outflow tract tachycardia with R/S transition in lead V3: six different anatomic approaches for successful ablation.
Tanner H, Hindricks G, Schirdewahn P, Kobza R, Dorszewski A, Piorkowski C, Gerds-Li JH, Kottkamp H.
J Am Coll Cardiol. 2005 Feb 1;45(3):418-23
Lessons from the limited value of surface ECG localizing the foci of idiopathic VTs.
Using the surface electrocardiogram to localize the origin of idiopathic ventricular tachycardia.
 Park KM, Kim YH, Marchlinski FE.
Pacing Clin Electrophysiol. 2012 Dec;35(12):1516-27.
Great overview about the surface ECG analysis of different form of idiopathic ventricular arrhythmias
The V(2) transition ratio: a new electrocardiographic criterion for distinguishing left from right ventricular outflow tract tachycardia origin.
Betensky BP, Park RE, Marchlinski FE, Hutchinson MD, Garcia FC, Dixit S, Callans DJ, Cooper JM, Bala R, Lin D, Riley MP, Gerstenfeld EP.
J Am Coll Cardiol. 2011May 31;57(22):2255-62.
This study analised the V2 transition ratio ≥0.6 predicts an LVOT origin with high sensitivity and specificity. A precordial transition later than the SR transition excludes an LVOT VT origin.


Decennial follow-up in patients with recurrent tachycardia originating from the right ventricular outflow tract: electrophysiologic characteristics and response to treatment.
Ventura R, Steven D, Klemm HU, Lutomsky B, Müllerleile K, Rostock T, Servatius H, Risius T, Meinertz T, Kuck KH, Willems S
 European Heart Journal 2007;28:2338-45
Large study on the long term outcome after catheter ablation of arrhythmia originating from the right ventricular outflow tract. Very helpful for electrophysiologists to estimate success rates and to correctly consent patients for catheter ablation of these patients.

Ablation of idiopathic ventricular tachycardia.
Schreiber D, Kottkamp H.
Curr  Cardiol Rep. 2010 Sep;12(5):382-8. Review.
The ablation of idiopathic ventricular arrhythmias is highly successful, associated with only rare complications. Newly recognized entities of idiopathic ventricular tachycardias are those originating in the papillary muscles and in the atrioventricular annular regions.


Electroanatomical substrate of idiopathic left ventricular tachycardia: unidirectional block and macroreentry within the purkinje network.
Ouyang F, Cappato R, Ernst S, Goya M, Volkmer M, Hebe J, Antz M, Vogtmann T, Schaumann A, Fotuhi P, Hoffmann-Riem M, Kuck KH:
Circulation 2002:105:462–469
Good overview on how to ablate idiopathic left ventricular tachycardia (ILVT) during VT and during sinus rhythm. Examples from intracardiac recordings as well as three dimensional CARTO maps are provided. Very helpful for electrophysiologists to ablate ILVT.


Characteristics of premature ventricular complexes as correlates of reduced left ventricular systolic function: study of the burden, duration, coupling interval, morphology and site of origin of PVCs.
Del Carpio Munoz F, Syed FF, Noheria A, Cha YM, Friedman PA, Hammill SC,Munger TM, Venkatachalam KL, Shen WK, Packer DL, Asirvatham SJ
J Cardiovasc Electrophysiol. 2011 Jul;22(7):791-8.
Frequent premature ventricular complexes (PVCs) can cause a decline in left ventricular ejection fraction (LVEF). The authors investigated whether the site of origin and other PVC characteristics are associated with LVEF.

Recovery from left ventricular dysfunction after ablation of frequent premature ventricular complexes.
Yokokawa M, Good E, Crawford T, Chugh A, Pelosi F Jr, Latchamsetty R,
Jongnarangsin K, Armstrong W, Ghambari H, Oral H, Morady F, Bogun F.
Heart Rhythm. 2012 Oct 23.
Patients with frequent premature ventricular complexes (PVCs) and PVC-induced cardiomyopathy usually have recovery of left ventricular (LV) dysfunction postablation. The time course of recovery of LV function has not been described. The authors demonstrated that PVC-induced cardiomyopathy resolves within 4 months of successful ablation in most patients. In about one-third of the patients, recovery is delayed and can take up to 45 months. An epicardial origin predicts delayed recovery of LV function.

Purkinje-related arrhythmias part I: monomorphic ventricular tachycardias.
Nogami A.
Pacing Clin Electrophysiol. 2011 May;34(5):624-50.

Electrocardiographic and electrophysiological characteristics in idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle: relevance for catheter ablation.
Yamada T, Doppalapudi H, McElderry HT, Okada T, Murakami Y, Inden Y, YoshidaY, Yoshida N, Murohara T, Epstein AE, Plumb VJ, Litovsky SH, Kay GN.
Circ Arrhythm Electrophysiol. 2010 Aug;3(4):324-31.
Radiofrequency catheter ablation of idiopathic papillary muscle (PAM) ventricular arrhythmias  is challenging probably because the origin is located relatively deep beneath the endocardium of the PAMs. PAM arrhytmias often exhibit multiple QRS morphologies, which may be caused by a single origin with preferential conduction resulting from the complex structure of the PAMs.


Idiopathic right ventricular arrhythmias not arising from the outflow tract: prevalence, electrocardiographic characteristics, and outcome of catheter ablation.
Van Herendael H, Garcia F, Lin D, Riley M, Bala R, Cooper J, Tzou W, Hutchinson MD, Verdino R, Gerstenfeld EP, Dixit S, Callans DJ, Tschabrunn CM, Zado ES, Marchlinski FE.
Heart Rhythm. 2011 Apr;8(4):511-8.
„Idiopathic VT/VPDs from the body of RV comprise an important subgroup of idiopathic RV VTs. Although most VTs originate from the RV free wall and nearly 50% from the TVA region, septal and more apical VTs are common. ECG characteristics distinguish free-wall versus septal and more apical origin of VTs, and RF catheter ablation provides good long-term arrhythmia control.”