Mapping and ablation of ventricular fibrillation-how and for whom?
Stephan Willems1, Boris A Hoffmann, Benjamin Schaeffer
1Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Martinistr. 52, 20246, Hamburg, Germany, willems@uke.uni-hamburg.de.
Insights
Identifying premature ventricular contractions (PVCs) originating from the Purkinje system is crucial for treating recurrent ventricular fibrillation (VF). Catheter ablation offers a targeted treatment option for these specific PVCs, improving patient outcomes.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Arrhythmias
Background:
- The Purkinje system's role in idiopathic ventricular fibrillation (VF) and polymorphic ventricular tachycardia (VT/VF) has been established.
- Identifying patients with recurrent VF/VT episodes and implantable cardioverter-defibrillator (ICD) shocks is critical, especially when triggered by premature ventricular contractions (PVCs).
- A common challenge is the absence of these triggering PVCs during electrophysiology (EP) lab procedures.
Purpose of the Study:
- To highlight the importance of identifying Purkinje system-mediated PVCs in patients with recurrent VF/VT.
- To discuss catheter ablation as a therapeutic strategy for these specific arrhythmias.
- To review the diagnostic criteria and long-term efficacy of ablation for Purkinje-related arrhythmias.
Main Methods:
- Screening Holter and ICD recordings to identify triggering PVCs.
- Utilizing local electrogram criteria, such as low amplitude, high-frequency Purkinje potentials preceding ventricular signals, to guide mapping and ablation.
- Reviewing published data on catheter ablation outcomes in various settings of Purkinje-related VT/VF.
Main Results:
- Catheter ablation has demonstrated favorable long-term follow-up in treating right and left ventricular Purkinje-related PVCs causing polymorphic VT/VF.
- Ablation has shown efficacy following myocardial infarction and in cases of right ventricular outflow tract-associated VF.
- Recent studies indicate epicardial ablation can suppress polymorphic VT/VF in Brugada syndrome, even without identifiable premature ventricular beats.
Conclusions:
- Catheter ablation is a valuable adjunctive therapy for managing Purkinje system-related PVCs causing recurrent polymorphic VT/VF.
- Identifying specific electrogram characteristics aids in the successful mapping and ablation of these arrhythmias.
- Ablation strategies, including epicardial approaches, offer effective long-term control for various forms of Purkinje-mediated ventricular arrhythmias.
Abstract:
The involvement of the Purkinje system in a subset of patients with idiopathic ventricular fibrillation or polymorphic VT/VF related to structural heart disease was first demonstrated in the pioneering work of Michel Haissaguerre and co-workers (Circulation 106:962-967, 2002 and Lancet 359:677-678, 2002). It is very important to identify these patients with recurrent episodes of ventricular fibrillation and/or ICD shocks with regard to the presence of triggering premature ventricular contractions (PVC), which may be amenable to mapping and catheter ablation by screening Holter and ICD recordings. The practical problem, which is frequently encountered, is the absence of these PVCs when the patients are brought to the EP lab. However, catheter ablation is an important adjunctive tool to antiarrhythmic drug treatment, beta blocker therapy, and general anesthesia in this setting. Local electrogram criteria related to this phenomenon have been identified guiding mapping and ablation (e.g., low amplitude, high-frequency Purkinje potentials preceding a closely coupled ventricular signal (Fig. 1a)). The favorable long-term follow-up after catheter ablation has been demonstrated in the setting of right and left ventricular Purkinje-related PVCs leading to polymorphic VT/VF (Leenhardt et al., Circulation 89:206-215, 1994) and also following myocardial infarction (Baensch et al., Circulation 108:3011-3016, 2003) and right ventricular outflow tract-associated VF (Noda et al., Journal of the American College of Cardiology 46:1288-1294, 2005). Most recently, epicardial ablation strategies leading to suppression of polymorphic VT/VF episodes related to the Brugada syndrome have been described irrespective to the presence of premature ventricular beats (Nademanee et al., Circulation 123:1270-1279, 2011).
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