Author + information
- Received August 20, 2019
- Revision received September 23, 2019
- Accepted September 26, 2019
- Published online December 16, 2019.
- aDivision of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- bDivision of Cardiovascular Medicine, Electrophysiology Service, University of Michigan, Ann Arbor, Michigan
- ↵∗Address for correspondence:
Dr. Francis E. Marchlinski, Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, Pennsylvania 19104.
• Catheter ablation has become a consistently effective strategy for recurrent VT.
• The role of VT ablation as a primary therapy for treating VT needs to be determined.
• Clinical trials addressing optimal timing, mortality benefit, and technique are needed.
• Emerging technologies may improve the safety and efficacy of VT ablation.
Although implantable cardioverter-defibrillators positively affect survival in patients at increased risk for arrhythmic sudden cardiac death, quality of life can be negatively affected by recurrent therapies. Ventricular tachycardia (VT) ablation targets clinical arrhythmias to prevent recurrence. Although treatment of VT initially required open heart surgery, it has since been replaced by percutaneous ablation, a safe and effective catheter-based therapy to ablate myocardium from either the endocardial or the epicardial surface. Four basic mapping techniques are used to guide VT ablation: activation, entrainment, and pace and substrate mapping. Current recommendations for VT ablation, especially in the setting of structural heart disease, mostly reserve this treatment for patients for whom antiarrhythmic therapy has failed or is not tolerated or desired. These recommendations derive from multiple observational reports and several randomized prospective studies in patients with VT in the setting of ischemic cardiac disease. Patients are usually referred late in their clinical course for VT ablation, limiting enrollment in clinical trials and resulting in limited prospective randomized data on long-term outcomes with ablative therapy. Future research efforts should address unmet needs, including more rigorous assessment of survival benefit from VT ablation, outcomes data of VT ablation in patients with nonischemic cardiomyopathy, and assessment of strategies to improve intramural substrate ablation. Emerging technologies with disruptive potential include the use of lower ionic strength irrigants, energy delivery guided by impedance modulation, simultaneous unipolar and bipolar ablation, and novel ablation catheters, including the retractable needle-tip electrode catheter. Promising alternatives to radiofrequency ablation include alcohol ablation from the coronary arterial or venous system, direct current or pulsed field electroporation, and stereotactic body radiotherapy guided by noninvasive substrate mapping. Future studies are needed to demonstrate the safety and efficacy of these novel technologies compared with standard radiofrequency catheter ablation.
- catheter ablation
- electroanatomic mapping
- ventricular fibrillation
- ventricular tachycardia
- ventricular tachycardia storm
This work was supported by the Katherine J. Miller EP Research Fund, the Mark Marchlinski EP Research and Education Fund, the Richard T. and Angela Clark Innovation Fund, and the Winkelman Family Fund in Cardiovascular Innovation. Dr. Marchlinski has served as consultant for Abbott Medical, Biosense Webster, Biotronik, Boston Scientific Inc., and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received August 20, 2019.
- Revision received September 23, 2019.
- Accepted September 26, 2019.
- 2019 American College of Cardiology Foundation
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