Abstract
The majority of ventricular tachycardias (VTs) occurs in patients with structural heart disease, predominantly coronary heart disease. Implantable cardioverter defibrillators (ICDs) are first-line therapy in patients with VT and structural heart disease. In patients who receive an ICD after a spontaneous sustained VT, recurrent VT episodes or an electrical storm are major problems. In addition, in patients with an ICD implanted for primary prevention of sudden cardiac death, 20% will experience at least one VT episode within 3–5 years after ICD implantation. Catheter ablation has a high acute success rate in eliminating clinical VT. However, several factors make catheter ablation of VT more difficult than ablation of supraventricular tachyarrhythmias. (1) The infarct region is often large. (2) The induced VT can be unstable or hemodynamically only poorly tolerated and therefore “unmappable”. (3) Though most commonly located in the subendocardium, the critical VT zone can occasionally be epicardial or intramural in location. (4) In many cases, several reentrant circuits may coexist making ablation of a single form of VT a palliative procedure which does not obviate the risk of sudden death. Thus, catheter ablation of sustained VT in the setting of structural heart disease can only be considered an adjunctive therapy which, in general, will require ICD therapy. Numerous “modern” mapping technologies have been developed, which have increased success rates of catheter ablation of VT in patients with and without structural heart disease. The aim of the present article is to review current three-dimensional mapping systems in comparison to conventional mapping and to describe a reasonable, tailored approach for the individual patient with VT.
Zusammenfassung
Die meisten ventrikulären Tachykardien (VT) treten bei Patienten mit struktureller Herzerkrankung auf. Implantierbare Kardioverter-Defibrillatoren (ICD) sind heutzutage Therapie der ersten Wahl bei diesen Patienten, um einen plötzlichen Herztod zu verhindern. Bei Patienten, die einen ICD nach Auftreten einer anhaltenden VT erhalten, besteht eine hohe Rezidivgefahr für erneute VT-Episoden. Darüber hinaus erleiden etwa 20% der Patienten, die primärprophylaktisch mit einem ICD versorgt werden, zumindest eine VT-Episode innerhalb von 3–5 Jahren nach ICD-Implantation. Die Katheterablation von VT stellt allein oder in Kombination mit einer medikamentösen antiarrhythmischen Therapie heutzutage eine wichtige Möglichkeit zur Behandlung von VT dar. Gegenüber der Ablationsbehandlung supraventrikulärer Tachykardien ist die Ablation von VT vielfach durch schlechte Auslösebedingungen, hämodynamische Instabilität während laufender Tachykardie und das Auftreten multipler VT erschwert. Vielfach liegen mehrere Reentrytachykardien vor, so dass die VT-Ablation bei struktureller Herzerkrankung in der Regel eine palliative Maßnahme ist. Demgegenüber kann die Mehrzahl von VT bei fehlender struktureller Herzerkrankung (sog. idiopathische VT) kurativ abladiert werden. Zur Ablation steht neben konventionellen Mapping-Verfahren heutzutage eine Reihe „moderner“ dreidimensionaler Mapping-Technologien zur Verfügung, mit deren Hilfe die Erfolgsraten von VT-Ablationen deutlich gestiegen sind. Ziel der vorliegenden Arbeit ist es, eine Übersicht über vorhandene dreidimensionale Mapping-Verfahren zu geben und deren Stellenwert bei der Katheterablation von VT zu diskutieren.
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Eckardt, L., Breithardt, G. Catheter Ablation of Ventricular Tachycardia. Herz 34, 187–196 (2009). https://doi.org/10.1007/s00059-009-3247-0
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DOI: https://doi.org/10.1007/s00059-009-3247-0