Sustained monomorphic ventricular tachycardia in patients with structural heart disease. Different arrhythmogenic substrates, different options of palliative and curative treatment in the era of three-dimensional mapping

Czech version

Authors: M. Fiala; J. Chovančík; R. Neuwirth; I. Nykl; H. Szymeczek; R. Nevřalová; O. Jiravský; M. Branny
Authors‘ workplace: Oddělení kardiologie, Kardiocentrum, Nemocnice Podlesí, Třinec, přednosta prim. MUDr. Marian Branny
Published in: Vnitř Lék 2006; 52(6): 577-589
Category: Original Contributions

Overview

Results of catheter ablation of sustained monomorphic ventricular tachycardia (SMVT) in patients with structural heart disease are presented.

Methods:
Catheter ablation was performed in 34 patients (5 females), aged 63 ± 11 years. One (3 %) patient had a permanent SMVT resistant to electric cardioversion, 13 (38 %) patients had incessant SMVT, 4 (12 %) patients had SMVT at least once a day, 9 (26 %) patients at least once a week, and 7 (21 %) patients at least once a month. Twenty-nine (85 %) patients were treated with amiodarone. Twenty-seven (79 %) patients had a history of remote myocardial infarction, 2 (6 %) patients presented with dilated cardimyopathy, 4 (12 %) patients had arrhythmogenic right ventricular cardimyopathy, and 1 (3 %) patient was after surgery for tetralogy of Fallot. Left ventricular ejection fraction was 35 ± 13 %. Ablation was mostly performed as a palliative approach with the purpose to eliminate clinically significant forms of SMVT leading to frequent ICD discharges, respectively to the worsening of heart failure. Less frequently, ablation was accomplished as a curative therapy. For the SMVT ablation, electroanatomic mapping was used, and, target or substrate mapping and ablation or their combinations were employed.

Results:
Clinical form of SMVT was successfully eliminated in 33 (97 %) patients, all inducible ventricular tachyarrhythmias were eliminated in 14 (41 %) patients. Any ventricular tachycardia did not recur in 29 (85 %) patients during 22 ± 17 months follow-up. Twenty-three (68 %) patients had eventually implanted ICD. Ablation was performed as a curative procedure in 11 (32 %) patients. Average procedure duration was 213 ± 56 minutes, fluoroscopy time was 18 ± 9 minutes, and number of radiofrequency applications was 23 ± 13.

Conclusion:
Catheter ablation in patients with structural heart disease offers a highly effective method in elimination of clinical forms of SMVT. In long-term perspective, it is associated with low recurrence of any ventricular tachyarrhythmia. Efficacy of the ablation in elimination of all inducible forms of ventricular tachyarrhythmia is lower and therefore it should be mostly viewed as a palliative method, particularly in patients with left ventricular dysfunction and incomplete revascularization.

Key words:
sustained monomorphic ventricular tachycardia - structural heart disease - catheter ablation - electroanatomic mapping

Sources

1. Arenal A, del Castillo S, Gonzales-Torrecilla E et al. Tachycardia-related channel in the scar tissue in patients with sustained monomorphic ventricular tachycardias. Circulation 2004; 110: 2568-2574.

2. Bogun F, Li Y-G, Groenefeld G et al. Prevalence of a shared isthmus in postinfarction patients with pleiomorphic, hemodynamically tolerated ventricular tachycardias. J Cardiovasc Electrophysiol 2002; 13: 237-241.

3. Brunckhorst C, Delacretaz E, Soejima K et al. Identification of the ventricular tachycardia isthmus after infarction by pacemapping. Circulation 2004; 110: 652-659.

4. Calkins H, Epstein A, Packer D et al. Catheter ablation of ventricular tachycardia in patients with structural heart disease using cooled radiofrequency energy. J Am Coll Cardiol 2000; 35: 1905-1914.

5. Fiala M. Doporučené postupy pro diagnostiku a léčbu supraventrikulárních tachyarytmií. Cor Vasa 2005; 47: 18-39.

6. Fiala M, Heinc P, Lukl J. Dlouhodobý efekt katetrové ablace komorové tachykardie u dospělých pacientů s předchozí operací vrozené srdeční vady. Dvě kazuistiky. Vnitř Lék 2003; 49: 143-147.

7. Fiala M, Chovančík J, Heinc P et al. Incisionální a neincisionální síňové makroreentry tachykardie u dospělých pacientů. Příčiny, principy mapování a dlouhodobé výsledky katetrové ablace. Vnitř Lék 2005; 51: 1236-1247.

8. Hsia HH, Callans DJ, Marchlinski FE. Characterization of endocardial electrophysiological substrate in patients with nonischemic cardimyopathy and monomorphic ventricular tachycardia. Circulation 2003; 108: 704-710.

9. Kumagai K, Yamauchi Y, Takahashi A et al. Idiopathic left ventricular tachycardia originating from the mitral annulus. J Cardiovasc Electrophysiol 2005; 16: 1029-1036.

10. Marchlinski FE, Callans DJ, Gottlieb CD et al. Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemia and nonischemic cardiomyopathy. Circulation 2000; 101: 1288-1296.

11. Marchlinski FE, Zado E, Dixit S et al. Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in setting of right ventricular cardiomyopathy. Circulation 2004; 110: 2293-2298.

12. Neužil P, Táborský M, Reddy V et al. Elektroanatomické trojrozměrné mapování arytmogenního substrátu a katetrizační radiofrekvenční ablace komorových tachykardií s využitím chlazených katetrů u nemocných po prodělaném infarktu myokardu - ověřovací studie. Cor Vasa 2002; 44: 244-248.

13. Soejima K, Delacretaz E, Suziki M et al. Saline-cooled versus standard radiofrequency catheter ablation for infarct- related ventricular tachycardias. Circulation 2001; 103: 1858-1862.

14. Sosa E, Scanavacca M. Epicardial mapping and ablation techniques to control ventricular tachycardia. J Cardiovasc Electrophysiol 2005; 16: 449-452.

15. Stevenson WG, Friedman PL, Kocovic D et al. Radiofrequency catheter ablation of ventricular tachycardia after myocardial infarction. Circulation 1998; 98: 308-314.

16. Stevenson WG, Sager PT, Friedman PL. Entrainment techniques for mapping atrial and ventricular tachycardias. J Cardiovasc Electrophysiol 1995; 6: 201-216.

17. Strickberger SA, Man KC, Daoud EG et al. A prospective evaluation of catheter ablation if ventricular tachycardia as adjuvant therapy in patients with coronary artery disease and an implantable cardioverter-defibrillator. Circulation 1997; 96: 1525-1531.

18. Verma A, Kilicaslan F, Schweikert RA et al. Short- and long-term success of substrate-based mapping and ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia. Circulation 2005; 111: 3209-3216.

19. Verma A, Marrouche NF, Schweikert RA et al. Relationship between successful ablation sites and the scar border zone defined by substrate mapping for ventricular tachycardia post-myocardial infarction. J Cardiovasc Electrophysiol 2005; 16: 465-471.