Stereotactic radiosurgery for ablation of ventricular tachycardia

Aims Stereotactic body radiotherapy (SBRT) for ventricular tachycardias (VTs) could be an option after failed catheter ablation. In this study, we analysed the long-term efficacy and toxicity of SBRT applied as a bail-out procedure. Methods and results Patients with structural heart disease and unsuccessful catheter ablations for VTs underwent SBRT. The planning target volume (PTV) was accurately delineated using exported 3D electroanatomical maps with the delineated critical part of re-entry circuits. This was defined by detailed electroanatomic mapping and by pacing manoeuvres during the procedure. Using the implantable cardioverter-defibrillator lead as a surrogate contrast marker for respiratory movement compensation, 25 Gy was delivered to the PTV using CyberKnife. We evaluated occurrences of sustained VT, electrical storm, antitachycardia pacing, and shock; time to death; and radiation-induced events. From 2014 until March 2017, 10 patients underwent radiosurgical ablation (mean PTV, 22.15 mL; treatment duration, 68 min). After radiosurgery, four patients experienced nausea and one patient presented gradual progression of mitral regurgitation. During the follow-up (median 28 months), VT burden was reduced by 87.5% compared with baseline (P = 0.012) and three patients suffered non-arrhythmic deaths. After the blanking period, VT recurred in eight of 10 patients. The mean time to first antitachycardia pacing and shock were 6.5 and 21 months, respectively. Conclusion Stereotactic body radiotherapy appears to show long-term safety and effectiveness for VT ablation in structural heart disease inaccessible to catheter ablation. We report one possible radiation-related toxicity and promising overall survival, warranting evaluation in a prospective multicentre clinical trial.

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Current Status and Future Directions of Ventricular Arrhythmia Ablation

European Cardiology Review ◽

10.15420/ecr.2010.6.3.77 ◽

2010 ◽

Vol 6 (3) ◽

pp. 77

Author(s):

Katja Zeppenfeld ◽

Martin J Schalij ◽

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Keyword(s):

Heart Disease ◽

Catheter Ablation ◽

Structural Heart Disease ◽

Current Status ◽

Electrical Storm ◽

Icd Implantation ◽

Life Saving ◽

Low Incidence ◽

Acute Results

Ventricular tachycardia (VT) catheter ablation has evolved over the past decade, allowing effective treatment of haemodynamically unstable and epicardial VTs in patients with structural heart disease previously not amenable to ablation. Catheter ablation reduces VT recurrences and thereby implantable cardioverter–defibrillator (ICD) shocks in 67–75% of patients, with a low incidence of procedure-related complications when performed in highly experienced centres. It can be life-saving in patients with electrical storm. Early use of ablation can be considered in selected patients who receive an ICD as an alternative to drug therapy provided that the procedure can be performed safely. Although acute results are promising, outcomes over the long-term are less favourable. An improved understanding of the VT substrate is mandatory for further advancement of a substrate-based ablation approach. Pre-procedural and intra-procedural imaging are likely to contribute to this. Whether catheter ablation will become first-line treatment for VT in structural heart disease and ultimately allow ICD implantation to be avoided in selected patients needs further evaluation.

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Long-term outcomes after catheter ablation of ventricular tachycardia in patients with and without structural heart disease

Heart Rhythm ◽

10.1016/j.hrthm.2016.07.001 ◽

2016 ◽

Vol 13 (10) ◽

pp. 1957-1963 ◽

Cited By ~ 68

Author(s):

Saurabh Kumar ◽

Jorge Romero ◽

Nishaki K. Mehta ◽

Akira Fujii ◽

Sunil Kapur ◽

...

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Catheter Ablation ◽

Structural Heart Disease ◽

Long Term Outcomes

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Predictors of long-term mortality after catheter ablation of ventricular tachycardia in a contemporary cohort of patients with structural heart disease

EP Europace ◽

10.1093/europace/euaa189 ◽

2020 ◽

Vol 22 (11) ◽

pp. 1672-1679

Author(s):

Angeliki Darma ◽

Livio Bertagnolli ◽

Borislav Dinov ◽

Federica Torri ◽

Alireza Sepehri Shamloo ◽

...

Keyword(s):

Heart Disease ◽

Structural Heart Disease ◽

Left Ventricular ◽

Male Gender ◽

Electrical Storm ◽

Term Outcome ◽

Long Term Outcome ◽

Ischaemic Cardiomyopathy

Abstract Aims Ablation of ventricular tachycardias (VTs) in patients with structural heart disease has been established in the past decades as an effective and safe treatment. However, the prognosis and long-term outcome remains poor. Methods and results We investigated 309 patients with ischaemic cardiomyopathy (ICM) and non-ischaemic cardiomyopathy (NICM) (186 ICM, 123 NICM; 271 males; mean age 64.1 ± 12 years; ejection fraction 34 ± 13%) after ≥1 VT ablations over a mean follow-up period of 34 ± 28 months. Electrical storm was the indication for 224 patients (73%), whereas 86 patients (28%) underwent epicardial as well as endocardial ablation. During follow-up, 132 patients (43%) experienced VT recurrence and 97 (31%) died. Ischaemic cardiomyopathy and NICM patients showed comparable results, regarding procedural endpoints, complications, VT recurrence and survival. The Cox-regression analysis for all-cause mortality revealed that the presence of higher left ventricular end-diastolic volume (LVEDV; P < 0.001), male gender (P = 0.018), atrial fibrillation (AF; P < 0.001), chronic obstructive pulmonary disease (COPD; P = 0.001), antiarrhythmic drugs during the follow-up (P < 0.001), polymorphic VTs (P = 0.028), and periprocedural complications (P = 0.001) were independent predictors of mortality. Conclusion Ischaemic cardiomyopathy and NICM patients undergoing VT ablation had comparable results regarding procedural endpoints, complications, VT recurrence and 3-year mortality. Higher LVEDV, male gender, COPD, AF, polymorphic VTs, use of antiarrhythmics, and periprocedural complications are strong and independent predictors for increased mortality. The PAINESD score accurately predicted the long-term outcome in our cohort.

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Faculty Opinions recommendation of Long-term outcomes after catheter ablation of ventricular tachycardia in patients with and without structural heart disease.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.726491738.793533548 ◽

2017 ◽

Author(s):

Brian Olshansky

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Catheter Ablation ◽

Structural Heart Disease ◽

Long Term Outcomes

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Catheter ablation of electrical storm in patients with structural heart disease

EP Europace ◽

10.1093/europace/euq364 ◽

2010 ◽

Vol 13 (1) ◽

pp. 109-113 ◽

Cited By ~ 45

Author(s):

M. Kozeluhova ◽

P. Peichl ◽

R. Cihak ◽

D. Wichterle ◽

V. Vancura ◽

...

Keyword(s):

Heart Disease ◽

Catheter Ablation ◽

Structural Heart Disease ◽

Electrical Storm

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Catheter Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease

US Cardiology Review ◽

10.15420/usc.2017:28:3 ◽

2018 ◽

Vol 12 (1) ◽

pp. 51-56 ◽

Cited By ~ 2

Author(s):

Timothy M Markman ◽

Daniel A McBride ◽

Jackson J Liang

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Catheter Ablation ◽

Structural Heart Disease ◽

Integrated Approach ◽

Implantable Cardioverter Defibrillators ◽

Therapeutic Modalities ◽

Fatal Arrhythmia ◽

Term Management

Ventricular tachycardia is a potentially fatal arrhythmia that occurs most frequently in patients with structural heart disease. Acute and long- term management can be complex, requiring an integrated approach with multiple therapeutic modalities including antiarrhythmic drugs, implantable cardioverter defibrillators, and catheter ablation. Each of these options has a role in management of ventricular tachycardia and are generally used in combination. It is essential to be aware that each approach has potential deleterious consequences that must be balanced while establishing a treatment strategy. Catheter ablation for ventricular tachycardia is performed with increasing frequency with rapidly evolving techniques. In this review, we discuss the acute and long-term management of ventricular tachycardia with a focus on techniques and evidence for catheter ablation.

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