Management Of Ventricular Tachycardia Research Articles

Pulsed-Field Ablation in Management of Ventricular Tachycardia: A Systematic Review of Case Reports and Clinical Outcomes.

Pulsed-field ablation (PFA) is a cutting-edge technique that employs non-thermal energy to cause cell death by inducing irreversible electroporation of cell membranes. This systematic review evaluates the PFA effectiveness as a potential alternative to radiofrequency and cryo-ablation for treating ventricular tachycardia. PubMed, Embase, Scopus, and Web of Science were systematically searched using keywords related to ventricular tachycardia and pulsed-field ablation. Eligible Studies evaluating this therapeutic approach for ventricular tachycardia were included in the final analysis. We included six studies (five case reports and one case series) in our systematic review. Eight (88.8%) of procedures were successful with 100% long-term efficacy. No procedural complications or ventricular tachycardia (VT) recurrence were observed in the cases. The absence of complications, high effectiveness, and long-term success rate make PFAs a good VT treatment option. However, PFA safety and efficacy studies for VT treatment are scarce. Thus, larger investigations on this topic are urgently needed.

Management of ventricular tachycardias: insights on centre settings, procedural workflow, endpoints, and implementation of guidelines-results from an EHRA survey.

Ventricular tachycardia (VT), and its occurrence, is still one of the main reasons for sudden cardiac death and, therefore, for increased mortality and morbidity foremost in patients with structural heart [Kahle A-K, Jungen C, Alken F-A, Scherschel K, Willems S, Pürerfellner H et al. Management of ventricular tachycardia in patients with ischaemic cardiomyopathy: contemporary armamentarium. Europace 2022;24:538-51]. Catheter ablation has become a safe and effective treatment option in patients with recurrent VT [Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N et al. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2020;17:e2-154]. Previous and current guidelines provide guidance on indication for VT ablation and risk assessment and evaluation of underlying disease. However, no uniform recommendation is provided regarding procedural strategies, timing of ablation, and centre setting. Therefore, these specifics seem to differ largely, and recent data are sparse. This physician-based European Heart Rhythm Association survey aims to deliver insights on not only infrastructural settings but also procedural specifics, applied technologies, ablation strategies, and procedural endpoints. Therefore, these findings might deliver a real-world scenario of VT management and potentially are of guidance for other centres.

Ventricular Tachycardia.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of ventricular tachycardia (VT) that is refractory to single dose anti-arrhythmic management. Electrical storm, defined as three or more episodes of sustained VT, ventricular fibrillation, or appropriate shocks from an implantable cardioverter defibrillator within 24 hours,1 has a mortality rate up to 14% in the first 48 hours.2 Ventricular tachycardia may present in a heterogenous fashion, not only with stable versus unstable clinical presentations, but also with different electrocardiographic morphologies and etiologies.1 Understanding how to rapidly diagnose, treat, and utilize second or third-line treatments is vital in the setting of refractory ventricular tachycardia rather than relying on the success of first-line agents. Appreciation for what medications are readily available in your crash cart and medication dispensing cabinet is critical for timely management for refractory ventricular tachycardia. At the conclusion of the simulation session, learners will be able to: 1) identify the different etiologies of VT, including structural heart disease, acute ischemia, and acquired or congenital QT syndrome; 2) describe confounding factors of VT, such as electrolyte abnormalities and sympathetic surge; 3) describe how to troubleshoot an unsuccessful synchronized cardioversion, including checking equipment connections, increasing delivered energy, and changing pad placement; 4) compare and contrast treatments of VT based on suspected underlying etiology; 5) describe reasons to activate the cardiac catheterization lab other than occlusive myocardial infarction; and 6) identify appropriate disposition of the patient to the cardiac catheterization lab. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of VT. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form3 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Twelve learners completed a feedback form. This session received 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated 5 scores. The lowest average score was 6.67 for "Before the simulation, the instructor set the stage for an engaging learning experience." The highest average score was 7 for "The instructor helped me see how to improve or how to sustain good performance." The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Excellent care and debrief." Specific scores are available upon request. This is a cost-effective method for reviewing VT diagnosis and management. The case may be modified for appropriate audiences, such as describing what medications may be readily available in a free-standing emergency department or pre-hospital setting. Medical simulation, ventricular tachycardia, cardiac emergencies, dysrhythmias, cardiology, emergency medicine.

Diagnosis and management of ventricular tachycardia

Ventricular tachycardia (VT) describes rapid heart rhythms originating from the ventricles. Accurate diagnosis of VT is important to allow prompt referral to specialist services for ongoing management. The diagnosis of VT is usually made based on electrocardiographic data, most commonly 12-lead echocardiography (ECG), as well as supportive cardiac telemetric monitoring. Distinguishing between VT and supraventricular arrhythmias on ECG can be difficult. However, the VT diagnosis frequently needs to be made rapidly in the acute setting. In this review, we discuss the definition of VT, review features of wide-complex tachycardia (WCT) on ECG that might be helpful in diagnosing VT, discuss the different substrates in which VT can occur and offer brief comments on management considerations for patients found to have VT.

Catheter ablation of ventricular tachycardia-Update2023

The management of ventricular tachycardias (VT), which are often associated with severe cardiac disease, is achallenging clinical task. The structural damage to the myocardium associated with cardiomyopathy is crucial to the occurrence of VT and plays afundamental role in arrhythmia mechanisms. The goal of catheter ablation is to develop an accurate understanding of the patient-specific arrhythmia mechanism as a first procedural step. As a second step, the ventricular areas that maintain the arrhythmia mechanism can be ablated and thereby electrically inactivated. Catheter ablation thereby enables causal therapy of VT by modifying the areas of the affected myocardium in such away that VT can no longer be triggered. The procedure is an effective treatment option for affected patients.

The Effectiveness of Catheter Ablation in the Management of Ventricular Tachycardia in Comparison With Antiarrhythmic Drugs in Patients With Structural Heart Disease: A Meta-Analysis.

The aim of this meta-analysis is to compare the safety and efficacy of catheter ablation versus antiarrhythmic drugs (AADs) in the management of ventricular tachycardia (VT) in patients with structural heart diseases. Two independent investigators searched electronic databases including PubMed, Cochrane, and Excerpta Medica database (EMBASE) using keywordcombinations (Medical Subject Headings (MeSH) terms and free terms)such as "catheter ablation," "ventricular tachycardia," "escalation," and "antiarrhythmic drugs" from inception to November 30, 2022. The primary efficacy outcomes included recurrence of VT at follow-up, all-cause mortality, and cardiovascular mortality. The secondary efficacy outcomes assessed in the current meta-analysis included implantable cardioverter-defibrillator (ICD) shock and hospitalization due to cardiac reasons. Safety outcomes included treatment-related adverse events and serious adverse events. A total of three studies were included in this meta-analysis. Therewas no significant difference in the risk of recurrence of VT (RR: 0.94, 95% CI: 0.72-1.24, p-value: 0.67), all-cause mortality (RR: 0.99, 95% CI: 0.67, 1.46, p-value: 0.98), cardiovascular mortality (risk ratio (RR): 0.90, 95% confidence interval (CI): 0.56-1.45, p-value: 0.67),incidence of ICD shocks (RR: 0.99, 95% CI: 0.76-1.29, p-value: 0.93, I-square: 0%), and hospitalization due to cardiac reasons in follow-up (RR: 0.77, 95% CI: 0.55-1.07, p-value: 0.12) between the catheter ablation group and the antiarrhythmic druggroup. However, the risk of treatment-related adverse events was lower in the ablation group compared to the antiarrhythmic medicine (AAM) group (RR: 0.44, 95% CI: 0.29-0.67, p-value: 0.0001). In this meta-analysis of three randomized controlled trials (RCTs) among patients with structural heart disease who had ventricular tachycardia, the incidence of the recurrence of VT, all-cause mortality, cardiovascular mortality, and ICD shock was not significantly different between patients who received catheter ablation and antiarrhythmic drugs. However, regarding safety, catheter ablation is a safe procedure with a low risk of treatment-related events compared to antiarrhythmic drugs.

Stereotactic Radiotherapy in the Management of Ventricular Tachycardias: More Questions than Answers?

Stereotactic body radiotherapy is a recent promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs) in patients with structural heart disease. Initial clinical experience with a single radiation dose of 25Gy shows reasonable efficacy in the reduction of VT recurrences with acceptable acute toxicity. Many unanswered questions remain, including unknown mechanism of action, variable time to effect, optimal method of substrate targeting, long-term safety, and definition of an optimal candidate for this treatment."

Recurrences after stereotactic arrhythmia radioablation for refractory ventricular tachycardia

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of ventricular tachycardia (VT) refractory to antiarrhythmic drugs and catheter ablation (CA). VT recurrences have been reported after STAR but the mechanisms remain poorly known. We analyzed recurrences in our patients (pts) after STAR for refractory VT. Methods From 09.2017 to 01.2020, 12 pts (66±8y, LVEF 40±14%) suffering from refractory VT were enrolled. The underlying cardiopathy was ischemic in 3, inflammatory in 3 and idiopathic in 6 pts. Nine out of 12 pts had a history of at least 1 electrical storm. Before STAR, an invasive electro-anatomical mapping of the VT substrate (VT-sub) was performed. A mean dose of 22±2Gy was delivered to the VT-sub using the Cyberknife system. Results The ablation volume was 24±7cc and involved the basal interventricular septum (IVS) in 10 pts. During the first 6 months after STAR, VT burden decreased by 95% (mean value, from 930 to 46 VT/semester). After a median follow-up of 14±10 months, 10/12 (83%) developed a recurrence as a sustained VT and underwent a redo CA. VT recurrence was located at the border zone (BZ) of the treated VT-sub in 6 cases, involved both the BZ and a larger substrate in 2 cases, and occurred remote from the VT-sub in 2 cases (see Table). The dose delivered at sites of VT recurrence was 9.9±8.6 Gy with a large heterogeneity ranging from 0.11 to 28.37 Gy, for some patients due to dose constraints near critical structures. Importantly no pts developed an AV block after STAR. Conclusion STAR appears to be an efficient tool for the management of IVS refractory VT, leading to a strong VT burden reduction and no AV block. Recurrences were nevertheless common, often at the border zone of the irradiated volume.

213 Efficacy and Feasibility of Rapid Early Intervention With Catheter Ablation (CA) compared to Anti-Arrhythmic Drugs (AADs) Alone for Management of Ventricular Tachycardia (VT) Storm: A Case Control Study

213 Efficacy and Feasibility of Rapid Early Intervention With Catheter Ablation (CA) compared to Anti-Arrhythmic Drugs (AADs) Alone for Management of Ventricular Tachycardia (VT) Storm: A Case Control Study

Evaluation and management of ventricular tachycardia in patients with dilated cardiomyopathy

Recurrent ventricular tachycardia (VT) is an important cause of increased morbidity and mortality in patients with non-ischemic dilated cardiomyopathy (DCM). Current recommendations for the treatment of VT in patients with structural heart disease mainly rely on data derived from patients with ischemic cardiomyopathy. Unlike postinfarction ischemic cardiomyopathy, DCM comprises multiple different etiologies with variable disease progression and prognosis, which often requires an individualized approach to risk stratification and treatment. Prevention of VT recurrence in DCM is challenging, especially when antiarrhythmic drugs are ineffective or contraindicated. The implantable cardioverter-defibrillator is in fact able to terminate but not prevent recurrent VT. Catheter ablation is the criterion standard for substrate-based treatment in DCM. However, the available data from recent studies on VT ablation in DCM are inconsistent and morphological and functional features of the arrhythmogenic substrates are poorly defined. Advanced substrate-based research is required to increase the understanding of arrhythmia mechanisms and improve ablation outcome in this heterogeneous patient population.

Decompensated Heart Failure With Ventricular Arrhythmia: How Useful Is VT Ablation?

Ventricular arrhythmias are common in patients with heart failure. Their management especially in the context of decompensated heart failure poses a clinical challenge to modern cardiologists. In this review article, we aim to summarise the current evidence on the epidemiology, pathophysiology, and management of ventricular tachycardia in heart failure, focusing primarily on the use of catheter ablation. The evolution of electro-anatomical mapping techniques and ablation catheter technology in the recent years has paved the path for the successful application of catheter ablation in the treatment of ventricular arrhythmias. The efficacy of catheter ablation in the management of ventricular tachycardia in patients with chronic heart failure has recently been the epicentre of a number of randomised controlled trials, demonstrating promising results with regard to arrhythmia suppression and all-cause mortality. The usefulness of catheter ablation in decompensated heart failure has been explored to a lesser degree, primarily in the setting of an electrical storm. Implantable cardiac defibrillators play the most important role in improving prognosis and preventing sudden cardiac death in patients with heart failure. Catheter ablation for the treatment of recurrent VT in patients with chronic heart failure is an efficacious strategy that can be applied adjunctively to or in instead of antiarrhythmic therapy, and it is highly successful at preventing recurrent ventricular tachycardia, ICD shocks. Its efficacy in the context of decompensated heart failure requires further research, with current evidence rendering its use promising.

Rescue procedure for an electrical storm using robotic non-invasive cardiac radio-ablation

Stereotactic body radiotherapy (SBRT) is an emerging non-invasive treatment in the management of ventricular tachycardia (VT). We report here an intensive care patient suffering from an electrical storm due to incessant VT, unresponsive to catheter ablation and anti-arrhythmic drugs, showing an immediate and durable response to electrophysiology-guided cardiac SBRT.

Management of ventricular tachycardia in the ablation era: results of the European Heart Rhythm Association Survey.

Patients with sustained ventricular tachycardia (VT) are at risk of sudden death. Treatment options for VT include antiarrhythmic drug therapy, insertion of an implantable cardioverter-defibrillator, and catheter ablation. Evidence on indications for VT ablation, timing, ablation strategies, and periprocedural management is sparse. The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate clinical practice regarding management of VT among the European countries. An electronic questionnaire was sent to members of the EHRA Electrophysiology Research Network. Responses were received from 88 centres in 12 countries. The results have shown that management of VTs is very heterogeneous across the participating centres. Indications, periprocedural management, and ablation strategies vary substantially. This EP Wire survey has revealed that catheter ablation is the first-line therapy for the treatment of recurrent monomorphic stable VT in patients without structural heart disease as well as in patients with ischaemic cardiomyopathy and impaired left ventricular ejection fraction in the majority of centres. Furthermore, in patients with ischaemic cardiomyopathy and the first episode of monomorphic VT, most centres (62.0%) performed catheter ablation. On the contrary, in patients with non-ischaemic cardiomyopathy, amiodarone (41.4%) and catheter ablation (37.1%) are used in a very similar proportion. Ablation strategies, endpoints, and post-ablation antithrombotic management vary substantially among European centres.

Pediatric Tachyarrhythmias: Diagnosis and Management

The purpose of this paper is to review the presentation, mechanism and acute management of pediatric tachyarrhythmias and to discuss current updates in the literature. In 2015, the AHA updated the PALS guidelines to include lidocaine as a first line agent alongside amiodarone in the management of ventricular tachycardia. A recent study re-addressed the safety of the use of adenosine on heart transplant patients with supraventricular tachycardia (SVT). Also, there have been recent studies which explored alternative prevention modalities for postoperative junctional ectopic tachycardia such as the use of dexmedetomidine and higher magnesium levels. This review discusses the mechanism, presentation, and management of pediatric tachyarrhythmias. It focuses on SVT, as it is the most common cardiac arrhythmia in children requiring intervention, but also discusses other life-threatening arrhythmias including ventricular arrhythmias and Wolff-Parkinson-White syndrome. It reviews the current updates in acute management and discusses future directions of prophylactic management.

0523: Right ventricular dysfunction and epsilon wave: new predicting factors of recurrence of VT after radiofrequency catheter ablation in arrhythmogenic right ventricular dysplasia/cardiomyopathy

Radiofrequency catheter ablation (RFCA) is increasingly used in the management of ventricular tachycardia (VT) in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVC/D) but it is associated with a high level of recurrences. To determine predictors associated with VT recurrence after RFCA in ARVC/D. This study included 85 consecutive patients referred to the Pitié Salpêtrière Hospital (Paris, France) who underwent a total of 149 RFCA procedures between 2000 and 2010. Predictors of recurrence of VT following RFCA were assessed by Cox regression. The mean age of the cohort was 36±13 years, 74 (87.1%) were men and 80 (95.2%) were proband. 70 (83.3%) experienced spontaneous VT before diagnosis. 30 (58.8%) patients required ≥2 procedures. In 13 (10.7%) patients, RFCA was performed through epicardial access. Over a mean follow- up of 114±60 months, the overall freedom from VT of the 149 procedures was 79%, and 56%, at 1 and 5 years, respectively. The presence of an epsilon wave and of right ventricular (RV) dysfunction (defined by RV angiography ejection fraction <40% or right area fractional change <35% by TTE) were associated with higher level of recurrences on multivariate analysis. The cumulative freedom from VT (Figure) in patients without RV dysfunction nor epsilon wave was 86% at 1 and 5 years, which was significantly longer than those without (76% and 47% respectively, P =0.003). Absence of RV dysfunction or of an epsilon wave are strongly associated with higher success after VT RFA in ARVC/D. Patients without those risk factors should therefore be considered as good candidates for VT ablation. Abstract 0523 – Figure: Survival analysis

How are arrhythmias detected by implanted cardiac devices managed in Europe? Results of the European Heart Rhythm Association Survey.

The management of arrhythmias detected by implantable cardiac devices can be challenging. There are no formal international guidelines to inform decision-making. The purpose of this European Heart Rhythm Association (EHRA) survey was to assess the management of various clinical scenarios among members of the EHRA electrophysiology research network. There were 49 responses to the questionnaire. The survey responses were mainly (81%) from medium-high volume device implanting centres, performing more than 200 total device implants per year. Clinical scenarios were described focusing on four key areas: the implantation of pacemakers for bradyarrhythmia detected on an implantable loop recorder (ILR), the management of patients with ventricular arrhythmia detected by an ILR or pacemaker, the management of atrial fibrillation in patients with pacemakers and cardiac resynchronization therapy devices and the management of ventricular tachycardia in patients with implantable cardioverter-defibrillators.

The role of catheter ablation in the management of ventricular tachycardia

The treatment strategy for ventricular tachycardia (VT) is guided by patient symptoms, the risk of sudden death estimated by VT mechanism and underlying cardiac structure, and the risk vs. benefit ratio of potential therapies. Over the last few decades, catheter ablation has emerged as the primary treatment of idiopathic VT and become an important management strategy in reducing VT burden in patients with structural heart disease. This article reviews the technique and outcomes of catheter ablation for ventricular arrhythmias as well as potential future directions for this procedure.

Management of patients with ventricular tachycardia in Europe: results of the European Heart Rhythm Association survey.

The purpose of this European Heart Rhythm Association (EHRA) survey was to assess clinical practice in the management of ventricular tachycardia (VT). The data are based on an electronic questionnaire sent to the members of the EHRA Research Network. Responses were received from 31 centres in 16 countries. The results of the survey show that the management of VT is in general in accordance with guidelines. Antiarrhythmic drugs are still frequently used for VT treatment. In patients at high risk of sudden cardiac death, an implantable cardioverter-defibrillator is routinely recommended, while the treatment options vary for patients with moderate or low risk. A discreet attitude is adopted for catheter ablation in high-risk patients as demonstrated by a relatively low rate of catheter ablation.

Management of Ventricular Tachycardia in the Setting of a Dedicated Unit for the Treatment of Complex Ventricular Arrhythmias

Background— We investigated the impact of catheter ablation on ventricular tachycardia (VT) recurrence and survival in a large number of patients with structural heart disease treated in the setting of a dedicated multiskilled unit. Methods and Results— Since January 2007, we have implemented a multidisciplinary model, aiming for a comprehensive management of VT patients. Programmed ventricular stimulation was used to assess acute outcome. Primary end points were VT recurrence and the occurrence of cardiac and sudden cardiac death. Overall, 528 patients were treated by ablation (634 procedures; 1–4 procedures per patient). Among 482 tested with programmed ventricular stimulation after the last procedure, a class A result (noninducibility of any VT) was obtained in 371 patients (77%), class B (inducibility of nondocumented VT) in 12.4%, and class C (inducibility of index VT) in 10.6%. After a median follow-up time of 26 months, VT recurred in 164 (34.1%) of 472 patients. VT recurrence was documented in 28.6% of patients with a class A result versus 39.6% of patients with class B and 66.7% with class C result (log-rank P &lt;0.001). The incidence of cardiac mortality was lower in class A patients than in those with class B and class C (8.4% versus 18.5% versus 22%, respectively; log-rank P =0.002). On the basis of multivariate analysis, postprocedural inducibility of index VT was independently associated both with VT recurrence (hazard ratio, 4.030; P &lt;0.001) and with cardiac mortality (hazard ratio, 2.099; P =0.04). Conclusions— Within a dedicated VT unit, catheter ablation prevents long-term VT recurrences, which may favorably affect survival in a large number of patients who have VT.

Enhancement of intracardiac navigation by new GPS-guided location system (MediGuide Technologies)

Ventricular tachycardia in patients with structural heart disease is a clinical relevant arrhythmogenic disorder. Many of these patients require a combination of implantable cardioverter-defibrillator (ICD) for prevention of sudden cardiac death with antiarrhythmic medications to decrease the frequency of ventricular tachycardia (VT) episodes. However, ICD cannot prevent arrhythmia episodes and medication has only limited efficacy and in relevant number of patients it has to be discontinued due to multiple side effects. Severalreportsinthelastdecadehaveshownthatinpatientswith frequently recurrent ventricular arrhythmia episodes catheter ablation can be a highly effective therapy as an adjunct to ICD and/or medical treatment. In addition, the SMASH-VT and VTACH trials demonstrates, that prophylactic VT ablation results in a prolonged time to recurrence of VT in patients with stable VT, previous myocardial infarction, and reduced left ventricular ejection fraction. 1,2 According to this data it is hardlysurprising that, besides atrialfibrillation ablation, treatment of ventricular tachycardia is the next big frontier in the field of interventional therapy of cardiac arrhythmias. However, management of ventricular tachycardia is still challenging driven by a complex three-dimensional substrate. Successful treatment requires a comprehensive understanding and visualization of cardiac anatomy and electrical activation. Beside conventional fluoroscopy, 3-D electromagnetic mapping systems have been introduced to facilitate catheter navigation. Currently used techniques have some weaknesses. For instance, fluoroscopy provides only two-dimensional information, where it is difficult to repeatedly guide the catheter to the same area of interest. Thus, with prolonged procedures there is an increased X-ray exposure, adding risk for both the patient and the physician. One limitation of available 3-D-mapping system is failing to sufficiently compensate for respiratory, cardiac cycle, and patient movement and the limited integration on fluoroscopy. Recently, a new intracardiac navigation system (MediGuide TM System) was introduced to overcome this limitation and to merge the key benefits of fluoroscopy and 3-D-mapping system in a unique manner. In the following we are going to introduce this technology and present potential implications on interventional treatment of ventricular arrhythmias.