Role of alternative interventional procedures when endo- and epicardial catheter ablation attempts for ventricular arrhythmias fail.

Kumar, Saurabh; Barbhaiya, Chirag R; Sobieszczyk, Piotr; Eisenhauer, Andrew C; Couper, Gregory S; Nagashima, Koichi; Mahida, Saagar; Baldinger, Samuel Hannes; Choi, Eue-Keun; Epstein, Laurence M; Koplan, Bruce A; John, Roy M; Michaud, Gregory F; Stevenson, William G; Tedrow, Usha B (2015). Role of alternative interventional procedures when endo- and epicardial catheter ablation attempts for ventricular arrhythmias fail. Circulation. Arrhythmia and electrophysiology, 8(3), pp. 606-615. Lippincott Williams & Wilkins 10.1161/CIRCEP.114.002522

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BACKGROUND

Ventricular tachycardia (VT) refractory to antiarrhythmic drugs and standard percutaneous catheter ablation techniques portends a poor prognosis. We characterized the reasons for ablation failure and describe alternative interventional procedures in this high-risk group.

METHODS AND RESULTS

Sixty-seven patients with VT refractory to 4±2 antiarrhythmic drugs and 2±1 previous endocardial/epicardial catheter ablation attempts underwent transcoronary ethanol ablation, surgical epicardial window (Epi-window), or surgical cryoablation (OR-Cryo; age, 62±11 years; VT storm in 52%). Failure of endo/epicardial ablation attempts was because of VT of intramural origin (35 patients), nonendocardial origin with prohibitive epicardial access because of pericardial adhesions (16), and anatomic barriers to ablation (8). In 8 patients, VT was of nonendocardial origin with a coexisting condition also requiring cardiac surgery. Transcoronary ethanol ablation alone was attempted in 37 patients, OR-Cryo alone in 21 patients, and a combination of transcoronary ethanol ablation and OR-Cryo (5 patients), or transcoronary ethanol ablation and Epi-window (4 patients), in the remainder. Overall, alternative interventional procedures abolished ≥1 inducible VT and terminated storm in 69% and 74% of patients, respectively, although 25% of patients had at least 1 complication. By 6 months post procedures, there was a significant reduction in defibrillator shocks (from a median of 8 per month to 1; P<0.001) and antiarrhythmic drug requirement although 55% of patients had at least 1 VT recurrence, and mortality was 17%.

CONCLUSIONS

A collaborative strategy of alternative interventional procedures offers the possibility of achieving arrhythmia control in high-risk patients with VT that is otherwise uncontrollable with antiarrhythmic drugs and standard percutaneous catheter ablation techniques.

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