Catheter ablation of ventricular tachycardia. From indication to three-dimensional mapping technology
Lars Eckardt1, Günter Breithardt
1Medizinischen Klinik und Poliklinik C, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany. l.eckardt@uni-muenster.de
Insights
Ventricular tachycardia (VT) ablation in structural heart disease is challenging but improved by modern 3D mapping. This review compares mapping systems and suggests tailored approaches for better patient outcomes.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Ventricular tachycardias (VTs) commonly occur in patients with structural heart disease, primarily coronary heart disease.
- Implantable cardioverter defibrillators (ICDs) are standard treatment, but recurrent VTs and electrical storms remain significant issues.
- Even with ICDs for primary prevention, a notable percentage of patients experience VT episodes within years of implantation.
Purpose of the Study:
- To review current three-dimensional (3D) mapping systems for ventricular tachycardia ablation.
- To compare these advanced systems with conventional mapping techniques.
- To outline a tailored, patient-specific approach for managing VT in structural heart disease.
Main Methods:
- Review of contemporary three-dimensional electroanatomic mapping technologies.
- Comparison of 3D mapping systems against traditional mapping methods.
- Analysis of factors influencing VT ablation success in structural heart disease.
Main Results:
- Catheter ablation demonstrates high acute success in eliminating VT but faces challenges in structural heart disease due to large infarcts, unstable VTs, varied substrate locations, and multiple reentrant circuits.
- Modern mapping technologies have enhanced success rates for VT ablation in patients with and without structural heart disease.
- VT ablation in structural heart disease is generally an adjunctive therapy requiring continued ICD support.
Conclusions:
- Despite challenges, catheter ablation is a valuable adjunctive therapy for VT in structural heart disease.
- Advanced 3D mapping systems offer improved efficacy and precision in identifying and ablating VT substrates.
- A personalized, tailored approach integrating advanced mapping is crucial for optimizing VT management and patient outcomes.
Abstract:
The majority of ventricular tachycardias (VTs) occurs in patients with structural heart disease, predominantly coronary heart disease. Implantable cardioverter defibrillators (ICDs) are first-line therapy in patients with VT and structural heart disease. In patients who receive an ICD after a spontaneous sustained VT, recurrent VT episodes or an electrical storm are major problems. In addition, in patients with an ICD implanted for primary prevention of sudden cardiac death, 20% will experience at least one VT episode within 3-5 years after ICD implantation. Catheter ablation has a high acute success rate in eliminating clinical VT. However, several factors make catheter ablation of VT more difficult than ablation of supraventricular tachyarrhythmias. (1) The infarct region is often large. (2) The induced VT can be unstable or hemodynamically only poorly tolerated and therefore "unmappable". (3) Though most commonly located in the subendocardium, the critical VT zone can occasionally be epicardial or intramural in location. (4) In many cases, several reentrant circuits may coexist making ablation of a single form of VT a palliative procedure which does not obviate the risk of sudden death. Thus, catheter ablation of sustained VT in the setting of structural heart disease can only be considered an adjunctive therapy which, in general, will require ICD therapy. Numerous "modern" mapping technologies have been developed, which have increased success rates of catheter ablation of VT in patients with and without structural heart disease. The aim of the present article is to review current three-dimensional mapping systems in comparison to conventional mapping and to describe a reasonable, tailored approach for the individual patient with VT.
