Θεραπεία κοιλιακής ταχυκαρδίας με διακαθετήρια κατάλυση με υψίσυχνο ρεύμα ( radiofrequency - RF ablation)

Abstract

Over the last 10 years radiofrequency catheter ablation (RFA) has been established as curative treatment of first choice for idiopathic ventricular tachycardia (VT), while implantable defibrillators (ICDs) are cosidered as first choice treatment for ventricular tachycardia with underying heart disease. The aim of the present study was to evaluate the success rate of RFA of VT in these 2 different subgroups of patients and the long-term results of this procedure. Methods: One hundred four patients were enrolled in the study, 75 men and 29 women, mean age 53±16 years, who underwent transcatheter radiofrequency ablation of sustained monomorphic ventricular tachycardia using the conventional mapping and ablating systems. Seventy-eight patients had underlying heart disease: thirteen patients arrhythmogenic right ventricular dysplasia (ARVD), 62 patients coronary artery disease (CAD) with remote myocardial infarction, 1 patient dilated cardiomyopathy (DCM), 1 patient sarcoidosis, 1 patient ventricular septal defect (VSD) corrected. Twenty six patients had idiopathic ventricular tachycardia: 21 patients right ventricular outflow tract (RVOT) VT, 3 patients left ventricular outflow tachycardia (LVOT) VT and 2 patients idiopathic fascicular tachycardia. The Westmead protocol which is more aggressive than the classic ones was used for programmed ventricular stimulation before and after the procedure. Success was defined according to the response to the above protocol at the end of the procedure as acute success, modified result and failed procedure. Results: Acute procedural success of VT RFA was achieved in 82% of the patients, 78% of those with underlying heart disease and 92% of those with idiopathic VT. Alternative treatment, antiarrhythmic surgery and ICD implantation was offered to all the patients with failed procedures and underlying heart disease. Initially 6 patients received an ICD and 4 patients underwent antiarrhythmic surgery. During a mean follow-up of 61 months, 96 patients were alive. Nineteen pts (18%) suffered VT recurrences, 97% of those who had an acutely successful procedure remained free of recurrent VT. The recurrence rate was 84% in the nonsuccessfully ablated group while it was 3% in the successfully ablated one; P< 0.001. The recurrence rate was 22% in patients with organic heart disease, 8% in the successful group and 88% in the failed procedure group. Analysis of survival free of recurrences of VT revealed significantly lower recurrence rate in patients with full or partial success. No patient died during or as consequence of the procedure. Eight of the patients with recurrent VT underwent a second successful procedure. During the long-term follow-up, there were 8 deaths from the group with underlying heart disease, 3 of non-cardiac causes, 3 of progressive heart failure and 1 of sudden arrhythmic death despite having an ICD inserted after a failed procedure and 1 of unknown cause following a modified result. Conclusions: VT RFA offers curative treatment to patients with idiopathic VT with rare recurrences. Although ICDs are considered the treatment of choice for VT with underlying heart disease they only offer VT termination but they do not prevent VT, while RFA is reasonable curative therapy for the patients of this group with high success rate and low recurrence rate. The acute success results using a standardized stimulation protocol at the time of RFA predict the long-term prognosis of the arrhythmia.