The role of catheter ablation in the management of patients with implantable cardioverter defibrillators presenting with electrical storm
Stelios ParaskevaidisDimitrios KonstantinouVassilios KolettasGeorge StavropoulosAthanasios KoutsakisChrysovalantou NikolaidouAntonios ZiakasHaralambos Karvounis
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Abstract:
Electrical storm (ES) is not uncommon among patients with an implantable cardioverter defibrillator (ICD) in situ. Catheter ablation (CA) may suppress the arrhythmia in the acute setting and prevent ES recurrence. Nineteen consecutive patients with an ICD in situ presenting with ES underwent electrophysiologic studies followed by CA. CA outcome was classified as a complete success if both clinical and non-clinical tachycardia were successfully ablated, partial success if ≥1 non-clinical tachycardia episodes were still inducible post–CA, and failure if clinical tachycardia could not be abolished. Patients were followed for a median period (IQR) of 5.6 (1.8-13.7) months. The primary endpoint was event-free survival from ES recurrence. The secondary endpoint was event-free survival from a composite of ES and/or sustained ventricular tachycardia (VT) recurrence. Clinical arrhythmia was successfully ablated in 14 out of 19 (73.7%) cases after a single CA procedure. A completely successful CA outcome was associated with significantly increased ES-free survival compared with a partially successful or failed procedure (Log rank P=0.039). Nevertheless, patients with acute suppression of all tachycardia episodes (n=11), relative to those with a partially successful or a failed CA procedure (n=8), did not differ in incidence of the composite endpoint of sustained VT or ES (Log rank P=0.278). A single CA procedure can acutely suppress clinical arrhythmia in three-quarters of cases. A completely successful CA outcome can prolong ES-free survival; however, sporadic ICD therapies cannot be abrogated.Keywords:
Clinical endpoint
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Catheter ablation has emerged as an important and effective treatment option for many recurrent ventricular arrhythmias. The approach to ablation and the risks and outcomes are largely determined by the nature of the severity and type of underlying heart disease. In patients with structural heart disease, catheter ablation can effectively reduce ventricular tachycardia (VT) episodes and implantable cardioverter defibrillator (ICD) shocks. For VT and symptomatic premature ventricular beats that occur in the absence of structural heart disease, catheter ablation is often effective as the sole therapy. Advances in catheter technology, imaging and mapping techniques have improved success rates for ablation. This review discusses current approaches to mapping and ablation for ventricular arrhythmias.
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Cardiac Ablation
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Over the last decades indications have broadened and techniques have been developed resulting in an increasing use of catheter ablation for different types of ventricular tachycardia (VT). Due to the high ablation success for non scar-related ventricular arrhythmia (VA) catheter ablation has become a first line therapy for symptomatic idiopathic VA or VA presumed to cause ventricular dysfunction. For the ablation of scar-related VTs individual patient factors and operator experience play an important role in risk-benefit considerations. However, the development of substrate based techniques, irrigated tip catheter ablation and the introduction of a percutaneous epicardial approach in selected patients has greatly enhanced the treatment of VTs in patients with structural heart disease. Understanding of the VT substrate in different diseases and individual patients is important for mapping and ablation. Advances in substrate imaging technologies and their integration during ablation procedures may provide more insights into the substrates and may guide VT ablation in the future. The distinction between scar-related and non scar-related VT is relevant because it may affect treatment and prognosis. Distinction between these entities may be facilitated by identification of the VT substrate during catheter mapping. Failure of catheter ablation is often due to the anatomical localization of the arrhythmic source or reentry circuit. However, evolving new catheter techniques and energy sources may overcome these limitations.
Reentry
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Purpose of review Drug-refractory ventricular tachycardia in the setting of structural heart disease results in frequent implantable cardioverter defibrillator therapies and an increased risk of heart failure. Management requires catheter ablation procedures for effective suppression of the arrhythmia. Recent findings Imaging and electroanatomic mapping technologies provide new insights into the myocardial structural abnormalities responsible for ventricular tachycardia. Integration of imaging data with three-dimensional mapping systems coupled with improved targeting of abnormal electrical signals may improve the ablation outcomes. New ablation tools show promise for the effective ablation of previously unreachable myocardial ventricular tachycardia circuits. Summary Catheter ablation procedures have evolved over the last 2 decades. Improved technology may contribute to more widespread utilization of catheter ablation in the future.
Refractory (planetary science)
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This article summarizes current understanding of the arrhythmia substrate and effect of catheter ablation for infarct-related ventricular tachycardia, focusing on recent findings.Clinical studies support the use of catheter ablation earlier in the course of ischemic disease with moderate success in reducing arrhythmia recurrence and shocks from implantable defibrillators, although mortality remains unchanged. Ablation can be lifesaving for patients presenting with electrical storm. Advanced mapping systems with image integration facilitate identification of potential substrate, and several different approaches to manage hemodynamically unstable ventricular tachycardia have emerged. Novel ablation techniques that allow deeper lesion formation are in development.Catheter ablation is an important therapeutic option for preventing or reducing episodes of ventricular tachycardia in patients with ischemic cardiomyopathy. Present technologies allow successful ablation in the majority of patients, even when the arrhythmia is hemodynamically unstable. Failure of the procedure is often because of anatomic challenges that will hopefully be addressed with technological progress.
Ischemic Cardiomyopathy
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Objective To report the clinical oberservation of 50 patients with implantable cardioverter defibrillator(ICD).Methods Observe the patients with ICD from May,1998 to Nov.2005.Results There were more than a thousand episodes of ventricular tachycardia ventricular fibrillation(VT/VF) detected and terminated by ICD devices.Conclusions ICD with tiered therapy function has high efficacy on the termination of ventricular tachyarrhythmias.It is important to follow up the patients and dynamically optimize the system of ICD.
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Newer devices incorporate advanced algorithms to have more accurate delivery of implantable cardioverter-defibrillator (ICD) therapy. Newer models of Abbott Implantable cardioverter-defibrillators like Gallant and Entrant have a new ventricular fibrillation (VF) therapy assurance algorithm. This algorithm has a proven role in avoiding under-detection of VF where some of the smaller electrograms are under-sensed. We report a case of ventricular fibrillation therapy assurance (VFTA) algorithm malfunction in a 48-year-old lady having single chamber Entrant Implantable cardioverter-defibrillator, where the patient received inappropriate therapies. The VFTA algorithm eventually had to be turned off.
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