Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
Highlights
1.2 Methods1.1 Document Scope and RationaleThe field of electrophysiology has undergone rapid progress in the last decade, with advances both in our understanding of the genesis of ventricular arrhythmias (VAs) and in the technology used to treat them
These include the anterior interventricular vein (AIV), which arises at the apex and runs along the anterior interventricular septum, connecting to the great cardiac vein (GCV) that continues in the AV groove to the coronary sinus (CS); the communicating vein located between aortic and pulmonary annulus; various posterior and lateral marginal branches or perforator veins; and the middle cardiac vein that typically runs along the posterior interventricular septum from the apex to join the CS or empty separately into the right atrium
Key Points & The right ventricle (RV) outflow tract (RVOT), pulmonary arteries, Sinuses of Valsalva (SV), left ventricle (LV) epicardium and endocardium contain most of the outflow tract arrhythmias. & Activation mapping and pace mapping can be used to guide ablation in the RVOT. & Imaging of coronary artery ostia is essential before ablation in the aortic SVs. & The LV summit is a challenging site of origin, often requiring mapping and/or ablation from the RVOT, LV outflow tract (LVOT), SVs, coronary venous system, and sometimes the epicardial space. & Deep intraseptal VA origins can be challenging to reach
Summary
The field of electrophysiology has undergone rapid progress in the last decade, with advances both in our understanding of the genesis of ventricular arrhythmias (VAs) and in the technology used to treat them. In light of advances in the treatment of VAs in the interim, and the growth in the number of VA ablations performed in many countries and regions [2, 3], an updated document is needed This effort represents a worldwide partnership between transnational cardiac electrophysiology societies, namely, HRS, EHRA, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS), and collaboration with ACC, AHA, the Japanese Heart Rhythm Society (JHRS), the Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardíacas [SOBRAC]), and the Pediatric and Congenital Electrophysiology Society (PACES). LOE A is derived from highquality randomized controlled trials; LOE B-R is derived from moderate-quality randomized controlled trials; LOE B-NR is derived from well-designed nonrandomized studies; LOE CLD is derived from randomized or nonrandomized studies with limitations of design or execution; and LOE C-EO indicates that a recommendation was based on expert opinion [7] Unique to this consensus statement is the systematic review commissioned for this document as part of HRS’s efforts to adopt the rigorous methodology required for guideline development. Recommendations were subject to a period of public comment, and the entire document underwent rigorous peer review by each of the participating societies and revision by the Chairs, before endorsement
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