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Treatment of chronic ventricular arrhythmias [proceedings]
Insights
Managing ventricular arrhythmias is challenging, requiring thorough documentation via Holter monitoring and investigation of underlying heart conditions. Treatment involves avoiding triggers, empirical antiarrhythmic trials, and potentially surgical interventions for refractory cases.
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Ventricular arrhythmias present a significant clinical challenge, demanding physician and patient commitment.
- Accurate diagnosis and risk stratification are crucial for effective management.
Purpose of the Study:
- To outline current strategies for the diagnosis and management of ventricular arrhythmias.
- To emphasize the importance of individualized treatment approaches and outcome documentation.
Main Methods:
- Comprehensive arrhythmia documentation using 24-hour Holter monitoring.
- Cardiac pathology assessment via echocardiography, coronary angiography, and left ventriculography.
- Systematic empirical trials of antiarrhythmic agents with serum level monitoring.
Main Results:
- Holter monitoring is preferred over exercise testing for arrhythmia documentation.
- Underlying cardiac conditions significantly influence prognostic significance and treatment goals.
- Surgical options like ventriculotomy, sympathectomy, and aneurysmectomy are considered for refractory cases.
Conclusions:
- Effective control of ventricular arrhythmias necessitates an individualized approach.
- Documentation of treatment effectiveness, often with repeated Holter monitoring, is essential.
- Surgical interventions are reserved for refractory cases, with electrophysiologic studies guiding selection for experimental procedures.
Abstract:
Treatment of ventricular arrhythmias at the present time is difficult and requires a strong commitment on the part of the physician and the patient. Adequate documentation of the arrhythmia with continuous ECG recordings (Holter recordings), preferably for 24 hours, should be performed in each case. Exercise testing can be utilized in selected patients, but is generally inferior to the Holter technique. Underlying cardiac pathology should be searched for, utilizing echocardiography in all patients and coronary angiography and left ventriculography in patients with more severe ventricular tachycardias. Estimation of the prognostic significance of the VPBs must be made in the context of the underlying disease, and goals for treatment must be set. Treatment in all cases first requires measures to avoid known precipitating factors. If antiarrhythmic therapy is utilized, a systematic empirical trial of available agents should be undertaken, utilizing repeated Holter monitoring to document effectiveness. Serum levels of the antiarrhythmic medications should be measured in most cases. Combinations of antiarrhythmic agents can be employed if the need is great, but the agents singly are ineffective. If treatment is determined to be ineffective, it should be discontinued. Surgical techniques may be useful in cases of refractory ventricular tachycardia, and they include overdrive pacing, surgical sympathectomy, or ventricular aneurysmectomy with or without coronary bypass. Coronary bypass alone or resection of a hypokinetic but not aneurysmal area of myocardium may be successful in some cases, but the results are less predictable than when a true aneurysm is resected. Electrophysiologic studies, performed as part of the preoperative evaluation and provoking a self-perpetuating ventricular tachycardia, may permit selection of patients suitable for ventriculotomy to interrupt the re-entry pathway. At present, this must be considered experimental and is performed in only a few centers equipped for the required complex epicardial mapping. Surgery has not been shown to affect complex VPBs outside the setting of acute ischemia. Control of ventricular arrhythmias requires a highly individualistic approach with documentation of effectiveness.