Strategies for the management of tachyarrhythmias

Conversion of atrial fibrillation or flutter is electrical and, if drugs fail to prevent recurrence, low energy His bundle ablation with implantation of a rate responsive pacemaker is our routine. For re-entry tachycardia, antitachycardia pacers are often the method of choice. We use bipolar automatically actuated systems exclusively, functioning either as burst overdrive or critically timed stimulation. His bundle, or accessory pathway ablation, is considered a later choice. Ventricular arrhythmias are initially terminated by by Class I agents or cardioversion and then a trial of suppressive drugs used. If this fails, a combination of an antitachycardia pacemaker plus an automatic implantable defibrillator is implanted. Alternative options are ablation of the arrhythmogenic site, endomyocardial stripping, or an encircling ventriculotomy with cardiac transplantation as the final option considered.