Novel Mapping Strategies for Ventricular Tachycardia Ablation

Despite advances in antiarrhythmic and device therapy, ventricular tachycardia (VT) continues to be a major cause of increased morbidity and mortality. During scar-mediated monomorphic ventricular tachycardia ablation, the search for critical isthmus sites continues to be the primary goal during successful ablative procedures. However, given the overwhelming hemodynamic instability of most ventricular arrhythmias (> 70%), VT ablation is increasingly performed during sinus rhythm. This technique requires either a greater reliance on isthmus surrogates, or more extensive ablation techniques and is a more probabilistic approach to substrate modification. We believe that a better understanding of scar physiology and activation during sinus rhythm has important implications for clinical workflow and mechanistic improvements with current ablation strategies. With advancements in high-density mapping and multi-electrode catheter technology, mapping of VT substrates is performed with higher resolution, with improved visualization of local abnormal ventricular activities (LAVA), and with a more nuanced functional understanding of late potentials. As a prerequisite, our practice for VT ablation starts with a high-density structural map to identify voltage abnormalities as well as an isochronal functional map of sinus rhythm activation to identify region of discontinuous wavefront propagation. As the era of increased automation has emerged, there continues to be vast array of customizable features, and we have adopted the use of multiple wavefront mapping to further elucidate possible arrhythmogenic substrate. Our emerging understanding of how scar propagation patterns relate to areas of abnormal signals and critical isthmuses may greatly improve the ability to identify surrogates during sinus rhythm and help localize the most arrhythmogenic regions within a given scar. In the hemodynamically unstable patients, we routinely integrate isochronal late activation mapping (ILAM) to identify areas of slow conduction to initiate our targeted ablation and substrate modification. Multi-electrode delineation of the entire reentrant VT circuit has value in understanding the size of the circuit, rotational nature, and transmural extent of human reentry. Correlative studies between the activation of the complete VT circuit and sinus rhythm are likely to provide important mechanistic insights on where fixed and/or functional block occurs within a complex scar substrate.