Current Cardiology Reports

, Volume 1, Issue 2, pp 157–164 | Cite as

Ablation of ventricular tachycardia in the setting of coronary artery disease

  • Allison W. Richardson
  • Mark E. Josephson
Article

Abstract

Ablation of reentrant ventricular tachycardia (VT) is an accepted therapy for certain patients with VT caused by coronary artery disease (CAD). Its use is currently limited to patients with sustained, monomorphic, hemodynamically tolerated VT. The use of entrainment in mapping reentrant VT has made possible increasingly accurate localization of critical sites on the reentrant pathway that are amenable to ablation. Recent work has examined the accuracy with which various mapping criteria are able to predict successful ablation of reentrant VT in patients with CAD. Other recent studies have investigated attempted ablation of all inducible VTs in patients with multiple VT morphologies. In the future, substrate mapping may make possible ablation of VT in patients with nonsustained or fast, hemodynamically unstable VTs, thus allowing VT ablation to become a first-line therapy for many patients with VT in the setting of CAD.

Keywords

Ventricular Tachycardia Implantable Cardioverter Defibrillator Monomorphic Ventricular Tachy Reentrant Circuit Ventricular Tachycardia Ablation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in to check access.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Wellens HJJ, Durer DR, Lie KI: Observations on mechanisms of ventricular tachycardia in man. Circulation 1976, 54:237.PubMedGoogle Scholar
  2. 2.
    Josephson ME, Buston AE, Marchlinski, et al.: Sustained ventricular tachycardia in coronary artery disease-evidence for reentrant mechanism. In Cardiac Electrophysiology and Arrhythmias. Edited by Zipes DP, Jalife J. Orlando: Grune & Stratton; 1985:409.Google Scholar
  3. 3.
    Josephson ME, Horowitz LN, Farshidi A, Kastor JA: Recurrent sustained ventricular tachycardia. 1. Mechanisms. Circulation 1978, 57:431.PubMedGoogle Scholar
  4. 4.
    El Sherif N, Scherlag BJ, Lazzara R: Electrode catheter recordings during malignant ventricular arrhythmias following experimental acute myocardial infarction. Circulation 1975, 51:1003.Google Scholar
  5. 5.
    Wit AL, Allessie MA, Bonke FIM, et al.: Electrophysiologic mapping to determine the mechanism of experimental ventricular tachycardia initiated by premature impulses. Experimental approach and initial results demonstrating reentrant excitation. Am J Cardiol 1982, 49:166.PubMedCrossRefGoogle Scholar
  6. 6.
    Josephson ME, Horowitz LN, Farshidi A: Continuous local electrical activity: a mechanism of recurrent ventricular tachycardia. Circulation 1978, 57:659.PubMedGoogle Scholar
  7. 7.
    Josephson ME, Harken AH, Horowitz LN: Endocardial excision: a new surgical technique for the treatment of recurrent ventricular tachycardia. Circulation 1979, 41:1035.Google Scholar
  8. 8.
    Cassidy DM, Vassallo JA, Buxton AE, et al.: The value of catheter mapping during sinus rhythm to localize site of origin of ventricular tachycardia. Circulation 1984, 6:1103.Google Scholar
  9. 9.
    Fenoglio JJ, Pham TC, Harken AH, et al.: Recurrent sustained ventricular tachycardia: structure and ultrastructure of subendocardial regions in which tachycardia originates. Circulation 1983, 69:518.Google Scholar
  10. 10.
    deBakker JMT, van Capelle FJL, Janse JM, et al.: Reentry as a cause of ventricular tachycardia in patients with chronic ischemic heart disease: electrophysiologic and anatomic correlates. Circulation 1988, 77:589.Google Scholar
  11. 11.
    Stevenson WG, Weiss JN, Weiner I, et al.: Fractionated endocardial electrograms are associated with slow conduction in humans: evidence from pace mapping. J Am Coll Cardiol 1989, 13:369.PubMedCrossRefGoogle Scholar
  12. 12.
    Josephson ME, Zimetbaum P, Huang D, et al.: Pathophysiologic substrate for ventricular tachycardia in coronary artery disease. Jpn Circ J 1997, 61:459.PubMedCrossRefGoogle Scholar
  13. 13.
    Wit AL, Dillon SM, Coromilas J, et al.: Anisotropic reentry in the epicardial border zone of myocardial infarcts. Ann NY Acad Sci 1990, 591:86.PubMedCrossRefGoogle Scholar
  14. 14.
    Almendral JM, Gottlieb CD, Rosenthal ME, et al.: Entrainment of ventricular tachycardia: explanation for surface electrocardiographic phenomena by analysis of electrograms recorded within the tachycardia circuit. Circulation 1988, 77:569.PubMedGoogle Scholar
  15. 15.
    Miller JM, Marchlinski FE, Buxton AE, Josephson ME: Relationship between the 12-lead electrocardiogram during ventricular tachycardia and endocardial site of origin in patients with coronary artery disease. Circulation 1988, 77:759.PubMedGoogle Scholar
  16. 16.
    Kienzle MG, Miller JM, Falcone RA, et al.: Intraoperative endocardial mapping during sinus rhythm: relationship to site of origin of ventricular tachycardia. Circulation 1984, 70:957.PubMedGoogle Scholar
  17. 17.
    Josephson ME, Waxman HL, Cain ME, et al.: Ventricular activation during ventricular endocardial pacing. II. Role of pace mapping to localize origin of ventricular tachycardia. Am J Cardiol 1982, 50:11.PubMedCrossRefGoogle Scholar
  18. 18.
    Anderson KP, Swerdlow CD, Mason JW: Entrainment of ventricular tachycardia. Am J Cardiol 1984, 53:335.PubMedCrossRefGoogle Scholar
  19. 19.
    Almendral JM, Stamato NJ, Rosenthal ME, et al.: Resetting response patterns during sustained ventricular tachycardia: relationship to the excitable gap. Circulation 1986, 74:722.PubMedGoogle Scholar
  20. 20.
    Rosenthal ME, Stamato NJ, Almendral JM, et al.: Resetting of ventricular tachycardia with electrocardiographic fusion: incidence and significance. Circulation 1988, 77:581.PubMedGoogle Scholar
  21. 21.
    Waldo AL, MacLean WAH, Karp RB, Kouchoukos NT, James TN. Entrainment and interruption of atrial flutter with atrial pacing. Circulation 1983, 67:73.PubMedGoogle Scholar
  22. 22.
    Josephson ME, Callans D, Almendral JM, et al.: Resetting and entrainment of ventricular tachycardia associated with infarction: clinical and experimental studies. In Tachycardias: Mechanisms and Management. Edited by Josephson ME, Wellens HJJ. Mount Kisco: Futura Publishing Co.; 1993:505.Google Scholar
  23. 23.
    Morady F, Kadish A, Rosenheck S, et al.: Concealed entrainment as a guide for catheter ablation of ventricular tachycardia in patients with prior myocardial infarction. J Am Coll Cardiol 1991, 17:678.PubMedCrossRefGoogle Scholar
  24. 24.
    Fontaine G, Frank R, Tonet J, Grosgogeat Y: Identification of a zone of slow conduction appropriate for ventricular tachycardia ablation: theoretical considerations. PACE 1989, 12:262.PubMedGoogle Scholar
  25. 25.
    Stevenson WG, Hafiza K, Sager P, et al.: Identification of reentry circuit sites during catheter mapping and radiofrequency ablation of ventricular tachycardia late after myocardial infarction. Circulation 1993, 88:I-1647.Google Scholar
  26. 26.
    Callans DJ, Zardini M, Bottlieb CD, Josephson ME: The variable contribution of functional and anatomic barriers in human ventricular tachycardia: an analysis with resetting from two sites. J Am Coll Cardiol 1996, 27:1106.PubMedCrossRefGoogle Scholar
  27. 27.
    Callans DJ, Hook BG, Josephson ME: Resetting not entrainment defines the characteristics of the ventricular tachycardia circuit in man. Circulation. 1991, 84:II-317.Google Scholar
  28. 28.
    Nath S, Dimarco J, Haines DE: Basic aspects of radiofrequency catheter ablation. J Cardiovasc Electrophysiol 1994, 5:863.PubMedCrossRefGoogle Scholar
  29. 29.
    •• Stevenson WG, Friedman PL, Sager PT, et al.: Exploring postinfarction reentrant ventricular tachycardia with entrainment mapping. J Am Coll Cardiol 1997, 29:1180.PubMedCrossRefGoogle Scholar

The authors investigated use of entrainment mapping criteria at 398 sites in 37 patients with CAD-related VT. They defined sites either as being on the isthmus, an inner loop, or the outer loop or as being adjacent or remote bystanders. The rate of successful termination of VT with RF current was significantly higher at sites on the isthmus (29%) than it was at all other sites (3%B11%)

  1. 30.
    •• Bogun MD, Bahu M, Knight BP, et al.: Comparison of effective and ineffective target sites that demonstrate concealed entrainment in patients with coronary artery disease undergoing radiofrequency ablation of ventricular tachycardia. Circulation 1997, 95:183.PubMedGoogle Scholar

The authors looked at use of entrainment mapping criteria in 14 patients with VT caused by previous MI. The positive predictive value of concealed entrainment alone for termination of VT with RF current was 54‰ If, in addition, S-QRS was equal to EG-QRS and less than 70% VTCL, the positive predictive value rose to 82‰ The presence of middiastolic potentials not dissociable from the QRS at sites that showed concealed entrainment was specific, but not sensitive, for successful termination of VT with RF current.

  1. 31.
    •• El-Shalakany A, Hadjis T, Papageorgiou P, et al.: Entrainment/ mapping criteria for the prediction of termination of ventricular tachycardia by single radiofrequency lesion in patients with coronary artery disease. Circulation, in press.Google Scholar

This study prospectively investigated use of entrainment mapping criteria to choose sites amenable to RFA in patients with CAD-related VT. The authors used strict criteria, including an exact QRS match by 12-lead ECG between VT entrained with concealed fusion and the patient's VT, PPI within 10 ms of VTCL, EG-QRS less than 70% VTCL, and S-QRS within 10 ms of EG-QRS, to predict sites at which VT would terminate with application of RF current. The positive predictive value of these criteria was 100%, and the negative predictive value was 96%

  1. 32.
    Wilber DJ, Davis MJ, Rosenbaum M, et al.: Incidence and determinants of multiple morphologically distinct sustained ventricular tachycardias. J Am Coll Cardiol 1987, 10:583.PubMedCrossRefGoogle Scholar
  2. 33.
    Kaltenbrunner W, Cardinal R, Dubuc M, et al.: Epicardial and endocardial mapping of ventricular tachycardia in patients with myocardial infarction. Is the origin of tachycardia always subendocardially localized? Circulation 1991, 84:1058.PubMedGoogle Scholar
  3. 34.
    Gonska B, Kejiang C, Schaumann A, et al.: Catheter ablation of ventricular tachycardia in 136 patients with coronary artery disease: results and long term follow up. J Am Coll Cardiol. 1994, 24:1506.PubMedCrossRefGoogle Scholar
  4. 35.
    Kim YH, Sosa-Suarez G, Trouton T, et al.: Treatment of ventricular tachycardia by transcatheter radiofrequency ablation in patients with ischemic heart disease. Circulation 1994, 89:1094.PubMedGoogle Scholar
  5. 36.
    Morady F, Harvey M, Kalbfleisch SJ, et al.: Radiofrequency catheter ablation of ventricular tachycardia in patients with coronary artery disease. Circulation 1993, 87:363.PubMedGoogle Scholar
  6. 37.
    Josephson ME, Harken AH, Horowitz LN: Long-term results of endocardial resection for sustained ventricular tachycardia in coronary disease patients. Am Heart J 1982, 104:51.PubMedCrossRefGoogle Scholar
  7. 38.
    Garan H, Nguyen K, McGovern BA, et al.: Perioperative and long-term results after electrophysiologically directed ventricular surgery for recurrent ventricular tachycardia. J Am Coll Cardiol 1986, 8:201.PubMedCrossRefGoogle Scholar
  8. 39.
    •• Callans DJ, Zado E, Sarter BH, et al.: Efficacy of radiofrequency catheter ablation for ventricular tachycardia in healed myocardial infarction. Am J Cardiol 1998, 82:429.PubMedCrossRefGoogle Scholar

This study looked at the success of VT ablation in all patients with CAD-related VT referred for potential ablation over 4 years. It differed from previous studies in that it was analyzed on an intention-to-treat basis; thus, it included patients referred for ablation who turned out not to have mappable VTs. Ablation of the clinical VT was initially successful in 58% of this patient population

  1. 40.
    •• Rothman SA, Hsia HH, Cossu SF, et al.: Radiofrequency catheter ablation of postinfarctrion ventricular tachycardia: longterm success and the significance of inducible nonclinical arrhythmias. Circulation 1997, 96:3499.PubMedGoogle Scholar

This study looked at VT ablation in 35 patients with CAD and multiple inducible VTs. The authors successfully ablated all mappable VTs in 31% of patients (considered complete successes) and successfully ablated the clinical VT in another 54% (considered partial successes). The recurrence rate was significantly higher in the group that had partially successful procedures than in the group with complete success; however, the partial success group started out with a significantly higher number of inducible VTs than did the complete success group

  1. 41.
    Stevenson WG, Friedman PL, Kocovic D, et al.: Radiofrequency catheter ablation of ventricular tachycardia after myocardial infarction. Circulation 1998, 98:308.PubMedGoogle Scholar

Copyright information

© Current Science Inc 1999

Authors and Affiliations

  • Allison W. Richardson
    • 1
  • Mark E. Josephson
    • 1
  1. 1.Beth Israel Deaconess Medical CenterBostonUSA

Personalised recommendations