News from the Heart Rhythm SocietyConsensus documentEHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA)
Section snippets
Preamble
The purpose of this Consensus Statement is to provide a state-of-the-art review of the field of catheter ablation of ventricular tachycardia (VT), and to report the findings of a Task Force, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS) that was charged with defining the indications, techniques, and outcomes of this procedure. This statement summarizes the opinion of the Task Force members based on their own experience in treating patients, as well
Table of Contents
- I
INTRODUCTION......887
- II
VENTRICULAR TACHYCARDIA: DEFINITIONS, MECHANISMS, AND RATIONALE FOR ABLATION......887
- III
INDICATIONS FOR CATHETER ABLATION OF VENTRICULAR TACHYCARDIA......891
- IV
TECHNICAL ASPECTS......891
- V
VENTRICULAR TACHYCARDIA IN STRUCTURAL HEART DISEASE......899
- VI
ABLATION OUTCOMES AND CONSIDERATIONS IN SPECIFIC DISEASES......908
- VII
IDIOPATHIC VENTRICULAR TACHYCARDIAS......913
- VIII
TRAINING AND INSTITUTIONAL REQUIREMENTS AND COMPETENCIES......916
- IX
CLINICAL TRIAL CONSIDERATIONS......918
- X
CONCLUSIONS......921
Definitions
Many terms have entered clinical usage to describe observations during mapping and ablation of VT. There has been substantial variation in the use of some terms by different investigators. The committee felt that these terms should be standardized to facilitate better understanding of methods, endpoints, and outcomes across centres (Table 1 and Figure 1).1, 2, 3, 4
Mechanisms and basis for catheter ablation of ventricular tachycardia
Monomorphic VT can occur in individuals with or without structural heart disease. The underlying heart disease and clinical
Indications for catheter ablation of ventricular tachycardia
Selection of catheter ablation for an individual patient should consider risks and benefits that are determined by patient characteristics, as well as the availability of appropriate facilities with technical expertise. In patients with structural heart disease, episodes of sustained VT are a marker for increased mortality and reduce quality of life in patients who have implanted defibrillators and structural heart disease.76, 77, 78, 79, 80 Antiarrhythmic medications can reduce the frequency
Technologies for mapping and ablation
Technological advances have been critical to the development of the field and will continue to play an important role in improving outcomes. The evaluation of new technologies has generally been based on uncontrolled series. There is limited head-to-head comparison of different technologies. Although new technologies generally increase the cost of a procedure when they are introduced, the costs may be justified if they improve outcomes.
The process of evaluation and adoption of new technologies
Ventricular tachycardia in structural heart disease
The most common cause of scar-related VT is a prior MI. The term non-ischaemic cardiomyopathy refers to all other causes of ventricular dysfunction. Myocardial fibrosis is almost always present in patients with non-ischaemic cardiomyopathies. However, the extent, location, and pattern of myocardial fibrosis vary greatly with the type of cardiomyopathy. Whereas most cardiomyopathic processes involve the LV predominantly, some, notably arrhythmogenic right ventricular dysplasia/cardiomyopathy
Prior myocardial infarction
Ventricular tachycardia occurs in 1–2% of patients late after MI, often after an interval of several years. Early reperfusion of infarct-related arteries results in less aneurysm formation, smaller scars, and less extensive electrophysiological abnormalities,311 although a significant risk of late VT (often with rapid cycle lengths) persists.312 In addition, the number of at-risk patients with chronic ischaemic cardiomyopathy due to multiple infarctions and late remodelling has increased due to
Idiopathic ventricular tachycardias
Idiopathic VT refers to VTs that occur in the absence of clinically apparent structural heart disease. These VTs occasionally occur in patients with structural heart disease, in whom the structural heart disease is not related to the VT. When frequent, they can be a cause of depressed ventricular function as a form of tachycardia-induced cardiomyopathy. Sudden death is rare, and therapy for idiopathic VTs is largely guided by symptoms. Ablation is a relatively effective option. Risks depend on
Training and institutional requirements and competencies
Catheter mapping and ablation in patients with potentially life-threatening ventricular arrhythmias is a challenging procedure that requires advanced technical and manual skills. Strategies, methods, and technology are evolving rapidly, and training and operator level requirements will change over time. Ventricular tachycardia ablation procedures should be performed in experienced, adequately equipped centres that have a dedicated electrophysiology programme that offers appropriate patient
Needs
Whereas several large randomized multicentre trials for ICD therapy assessing mortality have been performed, most knowledge of catheter ablation outcomes derives from single-centre studies. In most cases, these studies reflect the experience of large academic centres, the outcomes of which may or may not be replicated by smaller centres. The inherent design of such studies leave many questions unanswered. This section will address clinical trial considerations for the population of patients
Conclusions
Catheter ablation of VTs is increasingly performed. This document provides an up-to-date review of the indications, techniques, and outcomes. This statement summarizes the opinion of the task force members based on their analysis of the literature, as well as on their own experience in treating patients, and is directed to all healthcare professionals, healthcare institutions, manufacturers, and governmental, reimbursement, and regulatory bodies who are involved in the care of patients with
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