Abstract
Catheter ablation for ventricular tachycardia (VT) has been increasingly used over the past two decades in patients with structural heart disease (SHD). In these individuals, a substrate mapping strategy is being more commonly applied to identify targets for VT ablation, which has been shown to be more effective versus targeting mappable VTs alone. There are a number of substrate mapping methods in existence that aim to explore potential VT isthmuses, although their success rates vary. Most of the reported electrogram-based mapping studies have been performed with ablation catheters; meanwhile, the use of multipolar mapping catheters with smaller electrodes and closer interelectrode spacing has emerged, which allows for an assessment of detailed near-field abnormal electrograms at a higher resolution. Another recent advancement has occurred in the use of imaging techniques in VT ablation, particularly in refining the substrate. The goal of this paper is to review the key developments and limitations of current mapping strategies of substrate-based VT ablation and their outcomes. In addition, we briefly summarize the role of cardiac imaging in delineating VT substrate.
Highlights
Over the last decade, catheter ablation for ventricular tachycardia (VT) has been increasingly performed as an adjunctive therapy to antiarrhythmic drugs.[1,2] With this came an increased understanding of the mechanisms of VT; notably, it commonly results due to scar-related reentry in patients with structural heart disease (SHD)
A combination of several approaches is commonly employed during VT ablation, a number of studies have examined with variable results whether a substrate-based ablation strategy may be superior or comparable to one guided predominantly by the activation/entrainment mapping of inducible and hemodynamically tolerated VTs.[11,12,13,14,15,16,17,18]
We review substrate mapping and ablation strategies and clinical outcomes for VTs in the setting of SHD and discuss the importance of modalities for substrate detection in addition to those based on electrograms
Summary
Catheter ablation for ventricular tachycardia (VT) has been increasingly performed as an adjunctive therapy to antiarrhythmic drugs.[1,2] With this came an increased understanding of the mechanisms of VT; notably, it commonly results due to scar-related reentry in patients with structural heart disease (SHD). Substrate-based approaches involve the identification of local abnormal ventricular electrograms that represent diseased areas consistent with potential isthmuses capable of supporting reentrant VT and may be followed even when VTs are not inducible or not hemodynamically tolerated.[9,10] a combination of several approaches is commonly employed during VT ablation, a number of studies have examined with variable results whether a substrate-based ablation strategy may be superior or comparable to one guided predominantly by the activation/entrainment mapping of inducible and hemodynamically tolerated VTs.[11,12,13,14,15,16,17,18] Critical in achieving more successful results with a substrate-based approach is an accurate representation of the pathologic substrate; various strategies to delineate this have been proposed to date.[4,10,13,14,15,16,17,18,19,20,21,22]
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