Epicardial Ablation for Ventricular Tachycardia

Abstract

There has been an increasing number of patients presenting with ventricular tachycardia (VT) along with the growing use of implantable cardioverter-defibrillators. With the large multicenter studies having shown that ablation of VT successfully reduces recurrent VT, an increasing number of centers have begun to perform this procedure. However, for various reasons, after ablation some patients still experience VT recurrences. Further, in patients with dilated cardiomyopathy, arrhythmogenic right ventricular dysplasia /cardiomyopathy (ARVC/D), hypertrophic cardiomyopathy, and Chagas disease, endocardial ablation alone may be insufficient for preventing recurrent VT, because in those diseases the scar can often be transmural and spatially complex. Epicardial ablation can modify arrhythmogenic substrates more comprehensively. Along with the introduction of the percutaneous approach, the use of electroanatomic maps of the pericardial space has helped our understanding and characterization of the degree of the transmurality and anatomical distribution of the scar across various substrates. Furthermore, multiple observational studies have reported a greater freedom from recurrence with the addition of an adjunctive epicardial ablation than with endocardial ablation alone. Although generally only major medical centers perform epicardial ablation, having knowledge of the technical approach, clinical indications, and potential complications is very important in order to obtain the maximum clinical success and patient safety. In this chapter, we highlight the percutaneous approach and discuss the clinical indications and potential complications of scar-related epicardial ventricular tachycardia.