Interventional electrophysiology and its role in the treatment of cardiac arrhythmia

Cardiac arrhythmias can present as benign ectopics or as life-threatening arrhythmias and sudden cardiac death. Clinical cardiac electrophysiology is the study of the electrophysiology of the heart and all aspects of management of cardiac arrhythmias. The invasive electrophysiological study was initially purely diagnostic, but recent advances in technology has allowed us to intervene and hence the term interventional electrophysiology. The interventional therapies include permanent pacing for bradyarrhythmias, arrhythmia surgery for arrhythmias, percutaneous catheter ablation and implantable devices for tachyarrhythmias. The treatment of bradyarrhythmias with permanent pacemaker implantation represents the first interventional therapy for patients with cardiac arrhythmias. From 1973 to June 1996, a total of 791 pacemakers have been implanted at the Singapore General Hospital. Previously, patients with tachyarrhythmias could only be cured by open heart surgery utilising intraoperative map guided surgery and ablation of the arrhythmia. Only 17 patients with supraventricular tachycardia (SVT) and 3 patients with VT have undergone this procedure. Catheter ablation has completely revolutionised the treatment of these patients. From October 1991 until December 1996, 860 patients have undergone radiofrequency (RF) catheter ablation for SVT and non-ischaemic VT. Ninety-eight per cent of the patients with SVT have been successfully ablated and 94% of the patients with VT were successfully ablated. RF ablation has become the technique of choice to cure patients with recurrent paroxysmal SVT due to AV re-entrant tachycardia using an accessory pathway, AV nodal re-entrant tachycardia, atrial tachycardia and atrial flutter. It is also used for AV nodal ablation followed by pacemaker insertion or AV nodal modification in patients with poorly controlled atrial fibrillation. Patients with idiopathic non-ischaemic VT arising from the left ventricle or right ventricular outflow tract can similarly be cured. For all these patients, RF ablation offers curative therapy, thus eliminating recurrent symptoms, life-threatening attacks, tachycardia cardiomyopathy and need for life-long drug therapy. For patients with resuscitated sudden cardiac death or at high risk for sudden death, the implantable cardioverter defibrillator (ICD) is the only technique that has significantly improved survival from sudden cardiac death. Since August 1992, 11 patients have had the ICD implanted, with 9 surviving. The 2 deaths were due to cardiac failure and not to sudden death. Thus the ICD can prevent sudden death, but the main limitation is the cost of the device and it is not suitable in patients who have severe heart failure. In conclusion, interventional electrophysiology represents a tremendous leap forward in the management of cardiac arrhythmias. With catheter ablation, it offers a safe curative therapy for patients with recurrent SVTs and VTs and with the ICD, prevents sudden cardiac death in patients who have been resuscitated from it or who are at risk for it. The future will see us improving our success in ablating patients with monomorphic ischaemic VT and even atrial fibrillation, and the role of prophylactic ICDs in high risk patients will be better defined.