Ablation Approaches for Ventricular Fibrillation

  • Prabhpreet Singh
  • Amit Noheria
Arrhythmia (G Upadhyay, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Arrhythmia


Invasive electrophysiology (EP) mapping and catheter ablation has increasingly become the standard of care for many cardiac arrhythmias like supraventricular tachycardias, atrial fibrillation, premature ventricular complexes (PVC), and monomorphic ventricular tachycardia. In this review, we discuss the recent progress made in the mapping and ablation of ventricular fibrillation (VF). Ventricular activation during VF is apparently disorganized, making mapping and interpretation difficult. Prolonged mapping during VF would require mechanical circulatory support as VF causes complete hemodynamic collapse. These limitations have been addressed by the realization that there is often a reliable trigger arrhythmia that initiates the clinical VF episodes, and an approach to map and ablate this trigger can be successful. Such triggers can be PVCs localizing to the Purkinje/fascicular system, and in other cases can be ectopy from outflow tracts or intracavitary structures like papillary muscles, false tendons or moderator band, or can be monomorphic VT or preexcited atrial fibrillation that degenerate into VF. More recently, approaches beyond trigger elimination directly targeting the VF substrate have been devised. This includes elimination of the arrhythmogenic substrate localizing to the epicardial right ventricular outflow tract in patients with Brugada syndrome, akin to elimination of the arrhythmogenic substrate harbored by regions within scar in ischemic and non-ischemic cardiomyopathies. Further, recent attempts have been made to try to identify and ablate rotors during VF that may be important in perpetuating the VF episode. Such exciting advances in “curing” VF are proving to be life saving for resuscitated survivors of arrhythmic death.


Ablation Ventricular fibrillation Premature ventricular complexes 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.
  2. 2.
    Chugh SS, Reinier K, Teodorescu C, Evanado A, Kehr E, Al Samara M, et al. Epidemiology of sudden cardiac death: clinical and research implications. Prog Cardiovasc Dis. 2008;51(3):213–28.
  3. 3.
    Noheria A, Teodorescu C, Uy-Evanado A, Reinier K, Mariani R, Gunson K, et al. Distinctive profile of sudden cardiac arrest in middle-aged vs. older adults: a community-based study. Int J Cardiol. 2013;168(4):3495–9.
  4. 4.
    Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2013;61(3):e6–75.
  5. 5.
    Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, et al. EHRA/HRS expert consensus on catheter ablation of ventricular arrhythmias: developed in a partnership with the European heart rhythm association (EHRA), a registered branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Heart Rhythm. 2009;6(6):886–933.
  6. 6.
    Deyell MW, Krahn AD, Goldberger JJ. Sudden cardiac death risk stratification. Circ Res. 2015;116(12):1907–18. Scholar
  7. 7.
    • Viskin S, Adler A, Belhassen B. Idiopathic ventricular fibrillation. In: Gussak I, Antzelevitch C, editors. Electrical disease of the heart, volume 1. 2nd ed. London: Springer; 2013. p. 629–46. Excellent overview on evaluation and management of idiopathic ventricular fibrillation.
  8. 8.
    Myerburg RJ, Kessler KM, Castellanos A. Sudden cardiac death. Structure, function, and time-dependence of risk. Circulation. 1992;85(1 Suppl):I2–10.PubMedGoogle Scholar
  9. 9.
    • Ackerman M, Atkins DL, Triedman JK. Sudden cardiac death in the young. Circulation. 2016;133(10):1006–26. Good review on epidemiology of sudden cardiac death in young patients.
  10. 10.
    Jais P, Maury P, Khairy P, Sacher F, Nault I, Komatsu Y, et al. Elimination of local abnormal ventricular activities: a new end point for substrate modification in patients with scar-related ventricular tachycardia. Circulation. 2012;125(18):2184–96.
  11. 11.
    •• Krummen DE, Hayase J, Vampola SP, et al. Modifying ventricular fibrillation by targeted rotor substrate ablation: proof-of-concept from experimental studies to clinical VF. J Cardiovasc Electrophysiol. 2015;26(10):1117–26. Proof of concept of animal study showing feasibility of mapping to identify and ablation rotors that perpetuate ventricular fibrillation (VF) to make VF difficult to induce or non-inducible.
  12. 12.
    Krummen DE, Hayase J, Morris DJ, Ho J, Smetak MR, Clopton P, et al. Rotor stability separates sustained ventricular fibrillation from self-terminating episodes in humans. J Am Coll Cardiol. 2014;63(24):2712–21.
  13. 13.
    Aizawa Y, Tamura M, Chinushi M, Niwano S, Kusano Y, Naitoh N, et al. An attempt at electrical catheter ablation of the arrhythmogenic area in idiopathic ventricular fibrillation. Am Heart J. 1992;123(1):257–60.
  14. 14.
    •• Noheria A, Deshmukh A, Asirvatham SJ. Ablating premature ventricular complexes: justification, techniques, and outcomes. Methodist DeBakey Cardiovasc J. 2015;11(2):109–20. Good review with examples on procedural techniques for mapping and ablation of premature ventricular complexes (PVCs), including fascicular PVCs that may trigger ventricular fibrillation.
  15. 15.
    Haissaguerre M, Shah DC, Jais P, et al. Role of Purkinje conducting system in triggering of idiopathic ventricular fibrillation. Lancet. 2002;359(9307):677–8. Scholar
  16. 16.
    Haissaguerre M, Shoda M, Jais P, Nogami A, Shah DC, Kautzner J, et al. Mapping and ablation of idiopathic ventricular fibrillation. Circulation. 2002;106(8):962–7.
  17. 17.
    Knecht S, Sacher F, Wright M, Hocini M, Nogami A, Arentz T, et al. Long-term follow-up of idiopathic ventricular fibrillation ablation: a multicenter study. J Am Coll Cardiol. 2009;54(6):522–8.
  18. 18.
    Viskin S, Lesh MD, Eldar M, et al. Mode of onset of malignant ventricular arrhythmias in idiopathic ventricular fibrillation. J Cardiovasc Electrophysiol. 1997;8(10):1115–20. Scholar
  19. 19.
    Noda T, Shimizu W, Taguchi A, Aiba T, Satomi K, Suyama K, et al. Malignant entity of idiopathic ventricular fibrillation and polymorphic ventricular tachycardia initiated by premature extrasystoles originating from the right ventricular outflow tract. J Am Coll Cardiol. 2005;46(7):1288–94.
  20. 20.
    Van Herendael H, Zado ES, Haqqani H, Tschabrunn CM, Callans DJ, Frankel DS, et al. Catheter ablation of ventricular fibrillation: importance of left ventricular outflow tract and papillary muscle triggers. Heart Rhythm. 2014;11(4):566–73.
  21. 21.
    Santoro F, Di Biase L, Hranitzky P, et al. Ventricular fibrillation triggered by PVCs from papillary muscles: clinical features and ablation. J Cardiovasc Electrophysiol. 2014;25(11):1158–64. Scholar
  22. 22.
    Anter E, Buxton AE, Silverstein JR, Josephson ME. Idiopathic ventricular fibrillation originating from the moderator band. J Cardiovasc Electrophysiol. 2013;24(1):97–100. Scholar
  23. 23.
    Sadek MM, Benhayon D, Sureddi R, Chik W, Santangeli P, Supple GE, et al. Idiopathic ventricular arrhythmias originating from the moderator band: electrocardiographic characteristics and treatment by catheter ablation. Heart Rhythm. 2015;12(1):67–75.
  24. 24.
    Abouezzeddine O, Suleiman M, Buescher T, et al. Relevance of endocavitary structures in ablation procedures for ventricular tachycardia. J Cardiovasc Electrophysiol. 2010;21(3):245–54. Scholar
  25. 25.
    Haissaguerre M, Extramiana F, Hocini M, et al. Mapping and ablation of ventricular fibrillation associated with long-QT and Brugada syndromes. Circulation. 2003;108(8):925–8. Scholar
  26. 26.
    •• Nademanee K, Hocini M, Haissaguerre M. Epicardial substrate ablation for Brugada syndrome. Heart Rhythm. 2017;14(3):457–61. Contemporary review on the methods for identifying and effectively ablating the epicardial right ventricular outflow tract substrate to treat Brugada syndrome.
  27. 27.
    Nademanee K, Veerakul G, Chandanamattha P, Chaothawee L, Ariyachaipanich A, Jirasirirojanakorn K, et al. Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium. Circulation. 2011;123(12):1270–9.
  28. 28.
    Sunsaneewitayakul B, Yao Y, Thamaree S, Zhang S. Endocardial mapping and catheter ablation for ventricular fibrillation prevention in Brugada syndrome. J Cardiovasc Electrophysiol. 2012;23(Suppl 1):S10–6. Scholar
  29. 29.
    Yap J, Tan VH, Hsu LF, Liew R. Catheter ablation of ventricular fibrillation storm in a long QT syndrome genotype carrier with normal QT interval. Singap Med J. 2013;54(1):e1–4.CrossRefGoogle Scholar
  30. 30.
    Chan KH, Sy RW. Catheter ablation of recurrent ventricular fibrillation: a literature review and case examples. Heart Lung Circ. 2016;25(8):784–90. Scholar
  31. 31.
    Kautzner J, Peichl P. Catheter ablation of polymorphic ventricular tachycardia and ventricular fibrillation. Arrhythmia Electrophysiol Rev. 2013;2(2):135–40. Scholar
  32. 32.
    Bansch D, Oyang F, Antz M, et al. Successful catheter ablation of electrical storm after myocardial infarction. Circulation. 2003;108(24):3011–6. Scholar
  33. 33.
    Friedman PL, Stewart JR, Wit AL. Spontaneous and induced cardiac arrhythmias in subendocardial Purkinje fibers surviving extensive myocardial infarction in dogs. Circ Res. 1973;33(5):612–26. Scholar
  34. 34.
    Szumowski L, Sanders P, Walczak F, Hocini M, Jaïs P, Kepski R, et al. Mapping and ablation of polymorphic ventricular tachycardia after myocardial infarction. J Am Coll Cardiol. 2004;44(8):1700–6.
  35. 35.
    •• Haissaguerre M, Vigmond E, Stuyvers B, Hocini M, Bernus O. Ventricular arrhythmias and the His-Purkinje system. Nat Rev Cardiol. 2016;13(3):155–66. Review on the pathophysiologic role of the Purkinje/fascicular system in ventricular fibrillation (VF), and role of ablation of the arrhythmogenic Purkinje tissue in VF.
  36. 36.
    Enjoji Y, Mizobuchi M, Muranishi H, Miyamoto C, Utsunomiya M, Funatsu A, et al. Catheter ablation of fatal ventricular tachyarrhythmias storm in acute coronary syndrome—role of Purkinje fiber network. J Interv Card Electrophysiol: Int J Arrhythmias Pacing. 2009;26(3):207–15.
  37. 37.
    Marrouche NF, Verma A, Wazni O, Schweikert R, Martin DO, Saliba W, et al. Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy. J Am Coll Cardiol. 2004;43(9):1715–20.
  38. 38.
    Sinha AM, Schmidt M, Marschang H, et al. Role of left ventricular scar and Purkinje-like potentials during mapping and ablation of ventricular fibrillation in dilated cardiomyopathy. Pacing Clin Electrophysiol : PACE. 2009;32(3):286–90. Scholar
  39. 39.
    Kirubakaran S, Gill J, Rinaldi CA. Successful catheter ablation of focal ventricular fibrillation in a patient with nonischemic dilated cardiomyopathy. Pacing Clin Electrophysiol : PACE. 2011;34(4):e38–42. Scholar
  40. 40.
    Li YG, Gronefeld G, Israel C, Hohnloser SH. Catheter ablation of frequently recurring ventricular fibrillation in a patient after aortic valve repair. J Cardiovasc Electrophysiol. 2004;15(1):90–3. Scholar
  41. 41.
    • Syed FF, Ackerman MJ, McLeod CJ, et al. Sites of successful ventricular fibrillation ablation in bileaflet mitral valve prolapse syndrome. Circ Arrhythm Electrophysiol 2016;9(5). description of malignant bileaflet mitral valve prolapse syndrome with multiform ventricular ectopy from the papillary and fascicular (Purkinje) system causing ventricular fibrillation.
  42. 42.
    Mlcochova H, Saliba WI, Burkhardt DJ, et al. Catheter ablation of ventricular fibrillation storm in patients with infiltrative amyloidosis of the heart. J Cardiovasc Electrophysiol. 2006;17(4):426–30. Scholar
  43. 43.
    Good E, Desjardins B, Jongnarangsin K, Oral H, Chugh A, Ebinger M, et al. Ventricular arrhythmias originating from a papillary muscle in patients without prior infarction: a comparison with fascicular arrhythmias. Heart Rhythm. 2008;5(11):1530–7.
  44. 44.
    Wright M, Sacher F, Haissaguerre M. Catheter ablation for patients with ventricular fibrillation. Curr Opin Cardiol. 2009;24(1):56–60. Scholar
  45. 45.
    Nogami A. Purkinje-related arrhythmias part II: polymorphic ventricular tachycardia and ventricular fibrillation. Pacing Clin Electrophysiol: PACE. 2011;34(8):1034–49. Scholar
  46. 46.
    Lowery CM, Tzou WS, Aleong RG, et al. Use of stored implanted cardiac defibrillator electrograms in catheter ablation of ventricular fibrillation. Pacing Clin Electrophysiol: PACE. 2013;36(1):76–85. Scholar
  47. 47.
    Chen M. Ventricular tachycardia ablation and substrate modification in ICD patients with electrical storm. J Biomed Res. 2015;29(1):52–5. Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Tulane Heart and Vascular InstituteTulane UniversityNew OrleansUSA
  2. 2.Cardiac Electrophysiology Section, Cardiovascular DivisionWashington University School of MedicineSt. LouisUSA

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