Safety and Efficacy of Catheter Ablation for Ventricular Tachycardia in Elderly Patients With Structural Heart Disease

Around 10% of ventricular arrhythmias (VA) occur in the absence of underlying structural heart disease. These so-called ‘idiopathic’ VAs usually have a benign clinical course. Only rarely do these “benign” arrhythmias trigger polymorphic ventricular tachycardia (PVT) and idiopathic ventricular fibrillation (VF). Due to their focal origin and to the absence of underlying myocardial scar, the 12-lead ECG very precisely establishes the right (RV) or left (LV) ventricular site of origin of the arrhythmia and can help regionalizing the origin of VT for ablation. A 12-lead ECG obtained during the baseline rhythm and 24-hour ECG Holter monitoring are indicated in order to identify structural or electrical disorders leading to PVT/VF and to determine the VA burden. The most frequent origin of idiopathic VAs is the RV outflow tract (OT). Other origins include the LVOT, the LV fascicles (fascicular VTs), the LV and RV papillary muscles, the crux cordis, the mitral and tricuspid annuli and the RV moderator band. Recognizing the typical anatomic sites of origin combined with a 12 lead ECG assessment facilitates localization. Antiarrhythmic drug therapy (including use of beta-blockers) or catheter ablation may be indicated to suppress or eliminate idiopathic VAs, particularly upon severe arrhythmia-related symptoms or if the arrhythmia burden is high and ‘tachycardia’-induced cardiomyopathy is suspected. Catheter ablation is frequently preferred to prevent lifelong drug therapy in young patients.

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Sustained monomorphic ventricular tachycardia: the role of catheter ablation

ESC CardioMed ◽

10.1093/med/9780198784906.003.0539 ◽

2018 ◽

pp. 2279-2288

Author(s):

Tilman Maurer ◽

William G. Stevenson ◽

Karl-Heinz Kuck

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Catheter Ablation ◽

Sudden Cardiac Death ◽

Cardiac Death ◽

Therapeutic Option ◽

Structural Heart Disease ◽

Premature Ventricular Contractions ◽

Monomorphic Ventricular Tachycardia ◽

Premature Beats

Monomorphic ventricular tachycardia (VT) may occur in the presence or absence of structural heart disease. The standard therapy for patients with structural heart disease at high risk of sudden cardiac death due to VT is the implantable cardioverter defibrillator (ICD). While ICDs effectively terminate VT and prevent sudden cardiac death, they do not prevent recurrent episodes of VT, since the underlying arrhythmogenic substrate remains unchanged. However, shocks from an ICD increase mortality and impair quality of life. These limitations as well as continuous advancements in technology have made catheter ablation an important treatment strategy for patients with structural heart disease presenting with VT. Idiopathic ventricular arrhythmias include premature ventricular contractions and VT occurring in the absence of overt structural heart disease. In this setting, catheter ablation has evolved as the primary therapeutic option for symptomatic ventricular premature beats and sustained VTs and is curative in most cases. This chapter presents an overview of the principles of invasive diagnosis and treatment of monomorphic VTs in patients with and without structural heart disease and delineates the clinical outcome of catheter ablation. Finally, the chapter provides an outlook to the future, discussing potential directions and upcoming developments in the field of catheter ablation of monomorphic VT.

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