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Current Treatment Options in Cardiovascular Medicine

Open Access 25-04-2024 | Ventricular Tachycardia | Review

Challenges in Ventricular Arrhythmia Ablation: Difficult Substrates and Advanced Ablation Strategies

Authors: Łukasz Zarębski, MD, Piotr Futyma, MD, PhD, FESC, FEHRA

Published in: Current Treatment Options in Cardiovascular Medicine

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Abstract

Purpose of review

During challenging scenarios of ventricular arrhythmia (VA) ablation, novel strategies to target the arrhythmogenic substrate are sometimes essential for clinical success. While catheter ablation (CA) can offer relatively high efficacy, it may not always lead to complete VA eradication in certain individuals. This article provides a brief overview of difficult substrate ablation strategies in patients with premature ventricular contractions (PVC) or ventricular tachycardia (VT) and explores methods to improve outcomes for cases that do not respond to typical ablation techniques.

Recent findings

Recent developments highlight the crucial role of advanced imaging and mapping techniques in the visualization, characterization, and localization of challenging ventricular substrates. Additionally, some novel and advanced ablation strategies may be useful when PVC/VT is refractory to conventional ablation treatment.

Summary

An expanding spectrum of techniques which can optimize the precision and effectiveness of catheter ablation procedures may improve PVC/VT ablation outcomes. Novel ablation therapies such as alcohol ablation, optimization of dispersive patch positions, or bipolar ablation, can overcome obstacles associated with the challenging anatomy of arrhythmia.
Literature
1.
Vaseghi M, Hu TY, Tung R, Vergara P, Frankel DS, Di Biase L, et al. Outcomes of catheter ablation of ventricular tachycardia based on etiology in nonischemic heart disease: an international ventricular tachycardia ablation center collaborative study. JACC Clin Electrophysiol. 2018;4(9):1141–50.PubMedPubMedCentralCrossRef
2.
Chung FP, Lin YJ, Chang SL, Lo LW, Hu YF, Chen YY, et al. Long-term follow-up of catheter ablation of ventricular arrhythmias: experiences from a tertiary referral center in Taiwan. Acta Cardiol Sin. 2015;31(1):8–17.PubMedPubMedCentral
3.
Chung FP, Lin CY, Shirai Y, Futyma P, Santangeli P, Lin YJ, et al. Outcomes of catheter ablation of ventricular arrhythmia originating from the left ventricular summit: a multicenter study. Heart Rhythm. 2020;17(7):1077–83.PubMedCrossRef
4.
Huizar JF, Ellenbogen KA, Tan AY, Kaszala K. Arrhythmia-induced cardiomyopathy: JACC state-of-the-art review. J Am Coll Cardiol. 2019;73(18):2328–44.PubMedPubMedCentralCrossRef
5.
• Hanson M, Futyma P, Bode W, Liang JJ, Tapia C, Adams C, et al. Catheter ablation of intramural outflow tract premature ventricular complexes: a multicentre study. Europace. 2023;25(5):euad100. Findings from this study suggest that ablation of intramural PVCs is challenging and can sometimes require advanced ablation strategies to achieve acute success.PubMedPubMedCentralCrossRef
6.
Berte B, Sacher F, Venlet J, Andreu D, Mahida S, Aldhoon B, et al. VT recurrence after ablation: incomplete ablation or disease progression? A multicentric European study. J Cardiovasc Electrophysiol. 2016;27(1):80–7.PubMedCrossRef
7.
Roca-Luque I, Van Breukelen A, Alarcon F, Garre P, Tolosana JM, Borras R, et al. Ventricular scar channel entrances identified by new wideband cardiac magnetic resonance sequence to guide ventricular tachycardia ablation in patients with cardiac defibrillators. EP Europace. 2020;22(4):598–606.CrossRef
8.
John LA, Tomashitis B, Gowani Z, Levin D, Vo C, John I, et al. inHEART Models software - novel 3D cardiac modeling solution. Expert Rev Med Devices. 2023;20(10):797–803.PubMedCrossRef
9.
Kanawati J, De Silva K, Bhaskaran A, Turnbull S, Zhou J, Kotake Y, et al. Intracardiac echocardiography techniques to identify ventricular arrhythmia substrate. Heart Rhythm O2. 2022;3(5):602–12.PubMedPubMedCentral
10.
Kuwahara T. Intracardiac echocardiography in catheter ablation for atrial fibrillation: it is better to see what you are doing? J Atr Fibrillation. 2015;7(6):1215.PubMedPubMedCentral
11.
Dello Russo A, Compagnucci P, Bergonti M, Cipolletta L, Parisi Q, Volpato G, et al. Microelectrode voltage mapping for substrate assessment in catheter ablation of ventricular tachycardia: a dual-center experience. J Cardiovasc Electrophysiol. 2023;34(5):1216–27.CrossRef
12.
Berte B, Zeppenfeld K, Tung R. Impact of micro-, mini- and multi-electrode mapping on ventricular substrate characterisation. Arrhythm Electrophysiol Rev. 2020;9(3):128–35.PubMedPubMedCentralCrossRef
13.
Anderson RD, Rodriguez Padilla J, Joens C, Masse S, Bhaskaran A, Magtibay K, et al. On the electrophysiology and mapping of intramural arrhythmic focus. Circ Arrhythm Electrophysiol. 2022;15(5):e010384.PubMedCrossRef
14.
Segal OR, Wong T, Chow AWC, Jarman JWE, Schilling RJ, Markides V, et al. Intra-coronary guidewire mapping-a novel technique to guide ablation of human ventricular tachycardia. J Interv Card Electrophysiol. 2007;18(2):143–54.PubMedCrossRef
15.
Vlachos K, Letsas KP, Srinivasan NT, Frontera A, Efremidis M, Dragasis S, et al. The value of functional substrate mapping in ventricular tachycardia ablation. Heart rhythm O2. 2023;4(2):134–46.PubMedCrossRef
16.
Jackson N, Gizurarson S, Viswanathan K, King B, Massé S, Kusha M, et al. Decrement evoked potential mapping. Circ Arrhythm Electrophysiol. 2015;8(6):1433–42.PubMedCrossRef
17.
Porta-Sánchez A, Jackson N, Lukac P, Kristiansen SB, Nielsen JM, Gizurarson S, et al. Multicenter study of ischemic ventricular tachycardia ablation with decrement-evoked potential (DEEP) mapping with extra stimulus. JACC Clin Electrophysiol. 2018;4(3):307–15.PubMedCrossRef
18.
Vázquez-Calvo S, Garre P, Sanchez-Somonte P, Borras R, Quinto L, Caixal G, et al. Orthogonal high-density mapping with ventricular tachycardia isthmus analysis vs. pure substrate ventricular tachycardia ablation: a case–control study. Front Cardiovasc Med. 2022;9:912335.
19.
Jiang R, Beaser AD, Aziz Z, Upadhyay GA, Nayak HM, Tung R. High-density grid catheter for detailed mapping of sinus rhythm and scar-related ventricular tachycardia: comparison with a linear duodecapolar catheter. JACC Clini Electrophysiol. 2020;6(3):311–23.CrossRef
20.
Denham N, Ding WY, Campbell T, Modi S, Luther V, Todd D, et al. UltraSOUND-based characterization of ventricular tachycardia SCAR and arrhythmogenic substrate: THE SOUNDSCAR study. Heart Rhythm. 2024;21(1):45–53.PubMedCrossRef
21.
Liao Z, Zhan X, Wu S, Xue Y, Fang X, Liao H, et al. Idiopathic ventricular arrhythmias originating from the pulmonary sinus cusp: prevalence, electrocardiographic/electrophysiological characteristics, and catheter ablation. J Am Coll Cardiol. 2015;66(23):2633–44.PubMedCrossRef
22.
Zhang J, Tang C, Zhang Y, Su X. Pulmonary sinus cusp mapping and ablation: a new concept and approach for idiopathic right ventricular outflow tract arrhythmias. Heart Rhythm. 2018;15(1):38–45.PubMedCrossRef
23.
Heeger CH, Kuck KH, Ouyang F. Catheter ablation of pulmonary sinus cusp-derived ventricular arrhythmias by the reversed U-curve technique. J Cardiovasc Electrophysiol. 2017;28(7):776–7.PubMedCrossRef
24.
Futyma P, Moroka K, Derndorfer M, Kollias G, Martinek M, Pürerfellner H. Left pulmonary cusp ablation of refractory ventricular arrhythmia originating from the inaccessible summit. Europace. 2019;21(8):1253.PubMedCrossRef
25.
Liang Z, Wang Y, Zhang T, Han Z, Dong J, Ren X. Catheter ablation of ventricular arrhythmias with QRS morphology resembling that of aortic sinus cusp arrhythmias: significance of mapping the left pulmonary sinus cusp. J Cardiovasc Electrophysiol. 2018;29(4):591–9.PubMedCrossRef
26.
Dong X, Sun Q, Tang M, Zhang S. Catheter ablation of ventricular arrhythmias originating from the junction of the pulmonary sinus cusp via a nonreversed U curve approach. Heart Rhythm. 2019;16(10):1513–20.PubMedCrossRef
27.
Nagashima K, Choi EK, Lin KY, Kumar S, Tedrow UB, Koplan BA, et al. Ventricular arrhythmias near the distal great cardiac vein: challenging arrhythmia for ablation. Circ Arrhythm Electrophysiol. 2014;7(5):906–12.PubMedCrossRef
28.
Suresh A, Chang SL, Lin YJ, Lo LW, Chung FP, Chen SA. Ablation of ventricular tachycardia arising from the great cardiac vein – a rare cause of coronary artery injury. Acta Cardiol Sin. 2017;33(5):553–5.PubMedPubMedCentral
29.
Baszko A, Kałmucki P, Siminiak T, Szyszka A. Telescopic coronary sinus cannulation for mapping and ethanol ablation of arrhythmia originating from left ventricular summit. Cardiol J. 2020;27(3):312–5.PubMedPubMedCentralCrossRef
30.
Enriquez A, Malavassi F, Saenz LC, Supple G, Santangeli P, Marchlinski FE, et al. How to map and ablate left ventricular summit arrhythmias. Heart Rhythm. 2017;14(1):141–8.PubMedCrossRef
31.
Guandalini GS, Santangeli P, Schaller R, Pothineni NVK, Briceño DF, Enriquez A, et al. Intramyocardial mapping of ventricular premature depolarizations via septal venous perforators: differentiating the superior intraseptal region from left ventricular summit origins. Heart Rhythm. 2022;19(9):1475–83.PubMedCrossRef
32.
Tung R, Liu Q, Jiang R, Jiang C. Nonionic irrigated radiofrequency ablation of refractory incessant ventricular tachycardia via great cardiac vein. Heart Rhythm Case Rep. 2018;4(12):572–5.
33.
Nguyen DT, Tzou WS, Sandhu A, Gianni C, Anter E, Tung R, et al. Prospective multicenter experience with cooled radiofrequency ablation using high impedance irrigant to target deep myocardial substrate refractory to standard ablation. JACC Clin Electrophysiol. 2018;4(9):1176–85.PubMedCrossRef
34.
Hasegawa K, Yoneda ZT, Powers EM, Tokutake K, Kurata M, Richardson TD, et al. Safety of ventricular arrhythmia radiofrequency ablation with half normal saline irrigation. EP Europace. 2024;26(2):euae018.CrossRef
35.
Santangeli P, Marchlinski FE, Zado ES, Benhayon D, Hutchinson MD, Lin D, et al. Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit: outcomes and electrocardiogram correlates of success. Circ Arrhythm Electrophysiol. 2015;8(2):337–43.PubMedCrossRef
36.
37.
• Mueller J, Chakarov I, Halbfass P, Nentwich K, Ene E, Berkovitz A, et al. Adverse Prognosis of Patients With Septal Substrate After VT ablation due to electrical storm. JACC Clin Electrophysiol. 2023;9(6):790–804. In this study patients with septal substrate for VT were compared with patients without septal substrate. The first group had significantly decreased acute ablation successes and increased long-term cardiovascular mortality. VT recurrence rates were similar in both groups during follow-up.PubMedCrossRef
38.
Sultan A, Futyma P, Metzner A, Anic A, Richter S, Roten L, et al. Management of ventricular tachycardias: insights on centre settings, procedural workflow, endpoints, and implementation of guidelines-results from an EHRA survey. Europace. 2024;26(2):euae030.PubMedPubMedCentralCrossRef
39.
Neira V, Santangeli P, Futyma P, Sapp J, Valderrabano M, Garcia F, et al. Ablation strategies for intramural ventricular arrhythmias. Heart Rhythm. 2020;17(7):1176–84.PubMedCrossRef
40.
Kay GN, Epstein AE, Bubien RS, Anderson PG, Dailey SM, Plumb VJ. Intracoronary ethanol ablation for the treatment of recurrent sustained ventricular tachycardia. J Am Coll Cardiol. 1992;19(1):159–68.PubMedCrossRef
41.
Tavares L, Lador A, Fuentes S, Da-Wariboko A, Blaszyk K, Malaczynska-Rajpold K, et al. Intramural venous ethanol infusion for refractory ventricular arrhythmias: outcomes of a multicenter experience. JACC Clin Electrophysiol. 2020;6(11):1420–31.PubMedCrossRef
42.
Da-Wariboko A, Lador A, Tavares L, Dave AS, Schurmann PA, Peichl P, et al. Double-balloon technique for retrograde venous ethanol ablation of ventricular arrhythmias in the absence of suitable intramural veins. Heart Rhythm. 2020;17(12):2126–34.PubMedPubMedCentralCrossRef
43.
Futyma P, Chen S, Enriquez A, Pürerfellner H, Santangeli P. Bipolar ablation of ventricular arrhythmias: step-by-step. J Cardiovasc Electrophysiol. 2023;34(12):2599–606.PubMedCrossRef
44.
Teh AW, Reddy VY, Koruth JS, Miller MA, Choudry S, D’Avila A, et al. Bipolar radiofrequency catheter ablation for refractory ventricular outflow tract arrhythmias. J Cardiovasc Electrophysiol. 2014;25(10):1093–9.PubMedCrossRef
45.
Futyma P, Santangeli P, Pürerfellner H, Pothineni NV, Głuszczyk R, Ciąpała K, et al. Anatomic approach with bipolar ablation between the left pulmonic cusp and left ventricular outflow tract for left ventricular summit arrhythmias. Heart Rhythm. 2020;17(9):1519–27.PubMedCrossRef
46.
Enriquez A, Hanson M, Nazer B, Gibson DN, Cano O, Tokioka S, et al. Bipolar ablation involving coronary venous system for refractory left ventricular summit arrhythmias. Heart Rhythm O2. 2023;5(1):24–33.
47.
Futyma P, Sauer WH. Bipolar radiofrequency catheter ablation of left ventricular summit arrhythmias. Card Electrophysiol Clin. 2023;15(1):57–62.PubMedCrossRef
48.
Zhou B, Yu J, Ju W, Li X, Zhang F, Chen H, et al. Bipolar catheter ablation strategies for outflow tract ventricular arrhythmias refractory to unipolar ablation. J Cardiovasc Electrophysiol. 2022;33(8):1769–78.PubMedCrossRef
49.
Futyma P, Sander J, Ciąpała K, Głuszczyk R, Wysokińska A, Futyma M, et al. Bipolar radiofrequency ablation delivered from coronary veins and adjacent endocardium for treatment of refractory left ventricular summit arrhythmias. J Interv Card Electrophysiol. 2020;58(3):307–13.PubMedCrossRef
50.
Tokioka S, Fukamizu S, Kawamura I, Kitamura T, Hojo R. Bipolar radiofrequency catheter ablation between the left ventricular endocardium and great cardiac vein for refractory ventricular premature complexes originating from the left ventricular summit. J Arrhythm. 2020;36(2):363–6.PubMedPubMedCentralCrossRef
51.
Waight MC, Wiles BM, Li AC, Saba MM. Bipolar radiofrequency ablation of septal ventricular tachycardia facilitated by an intramural catheter. JACC Case Rep. 2021;3(8):1119–24.PubMedPubMedCentralCrossRef
52.
Futyma P, Ciąpała K, Sander J, Głuszczyk R, Futyma M, Kułakowski P. Bipolar radiofrequency ablation of ventricular arrhythmias originating in the vicinity of his bundle. Circ Arrhythm Electrophysiol. 2020;13(3):e008165.PubMedCrossRef
53.
Futyma P, Kułakowski P. Bipolar ablation delivered between the pulmonary and aortic valve cusps. Rev Esp Cardiol (Engl Ed). 2019;72(12):1078.PubMedCrossRef
54.
Futyma P, Wysokińska A, Sander J, Futyma M, Kułakowski P. Bipolar endo-epicardial radiofrequency ablation of arrhythmia originating from the left ventricular summit. Circ J. 2018;82(6):1721–2.PubMedCrossRef
55.
Igarashi M, Nogami A, Fukamizu S, Sekiguchi Y, Nitta J, Sakamoto N, et al. Acute and long-term results of bipolar radiofrequency catheter ablation of refractory ventricular arrhythmias of deep intramural origin. Heart Rhythm. 2020;17(9):1500–7.PubMedCrossRef
56.
Futyma P, Kułakowski P. Frontal placement of dispersive patch for effective ablation of arrhythmia originating from the anterior right ventricular outflow tract. J Interv Card Electrophysiol. 2017;49(3):327.PubMedCrossRef
57.
Barkagan M, Rottmann M, Leshem E, Shen C, Buxton AE, Anter E. Effect of baseline impedance on ablation lesion dimensions. Circ Arrhythm Electrophysiol. 2018;11(10):e006690.PubMedCrossRef
58.
Wei C, Qian P, Tedrow U, Mak R, Zei PC. Non-invasive stereotactic radioablation: a new option for the treatment of ventricular arrhythmias. Arrhythm Electrophysiol Rev. 2019;8(4):285–93.PubMedCentralCrossRef
59.
Cozzi S, Bottoni N, Botti A, Trojani V, Alì E, Finocchi Ghersi S, et al. The use of cardiac stereotactic radiation therapy (SBRT) to manage ventricular tachycardia: a case report, review of the literature and technical noTes. J Pers Med. 2022;12(11):1783.PubMedPubMedCentralCrossRef
60.
Cuculich PS, Schill MR, Kashani R, Mutic S, Lang A, Cooper D, et al. Noninvasive cardiac radiation for ablation of ventricular tachycardia. N Engl J Med. 2017;377(24):2325–36.PubMedPubMedCentralCrossRef
61.
• Kautzner J, Jedlickova K, Sramko M, Peichl P, Cvek J, Ing LK, et al. Radiation-induced changes in ventricular myocardium after stereotactic body radiotherapy for recurrent ventricular tachycardia. JACC Clin Electrophysiol. 2021;7(12):1487–92. This study revealed that SBRT may be promising option for VT treatment especially in patients after previously failed catheter ablation.PubMedCrossRef
62.
Ninni S, Gallot-Lavallée T, Klein C, Longère B, Brigadeau F, Potelle C, et al. Stereotactic radioablation for ventricular tachycardia in the setting of electrical storm. Circ Arrhythm Electrophysiol. 2022;15(9):e010955.PubMedCrossRef
63.
Amino M, Yoshioka K, Tanabe T, Tanaka E, Mori H, Furusawa Y, et al. Heavy ion radiation up-regulates Cx43 and ameliorates arrhythmogenic substrates in hearts after myocardial infarction. Cardiovasc Res. 2006;72(3):412–21.PubMedCrossRef
64.
Schmidt B, Bordignon S, Neven K, Reichlin T, Blaauw Y, Hansen J, et al. EUropean real-world outcomes with pulsed field ablation in patients with symptomatic atRIAl fibrillation: lessons from the multi-centre EU-PORIA registry. Europace. 2023;25(7):euad185.PubMedPubMedCentralCrossRef
65.
Koruth JS, Kuroki K, Iwasawa J, Viswanathan R, Brose R, Buck ED, et al. Endocardial ventricular pulsed field ablation: a proof-of-concept preclinical evaluation. EP Europace. 2020;22(3):434–9.CrossRef
66.
Im SI, Higuchi S, Lee A, Stillson C, Buck E, Morrow B, et al. Pulsed field ablation of left ventricular myocardium in a swine infarct model. JACC Clin Electrophysiol. 2022;8(6):722–31.PubMedCrossRef
67.
Stewart MT, Haines DE, Verma A, Kirchhof N, Barka N, Grassl E, et al. Intracardiac pulsed field ablation: Proof of feasibility in a chronic porcine model. Heart Rhythm. 2019;16(5):754–64.PubMedCrossRef
68.
69.
Lozano-Granero C, Hirokami J, Franco E, Tohoku S, Matía-Francés R, Schmidt B, Hernández-Madrid A, Zamorano Gómez JL, Moreno J, Chun J. Case Series of Ventricular Tachycardia Ablation With Pulsed-Field Ablation: Pushing Technology Further (Into the Ventricle). JACC Clin Electrophysiol. 2023;9(9):1990–4.
70.
Ouss A, van Stratum L, van der Voort P, Dekker L. First in human pulsed field ablation to treat scar-related ventricular tachycardia in ischemic heart disease: a case report. J Interv Card Electrophysiol. 2023;66(3):509–10.PubMed
71.
Reddy VY, Petru J, Funasako M, Kopriva K, Hala P, Chovanec M, et al. Coronary arterial spasm during pulsed field ablation to treat atrial fibrillation. Circ. 2022;146(24):1808–19.CrossRef
Metadata
Title
Challenges in Ventricular Arrhythmia Ablation: Difficult Substrates and Advanced Ablation Strategies
Authors
Łukasz Zarębski, MD
Piotr Futyma, MD, PhD, FESC, FEHRA
Publication date
25-04-2024
Publisher
Springer US
Published in
Current Treatment Options in Cardiovascular Medicine
Print ISSN: 1092-8464
Electronic ISSN: 1534-3189
DOI
https://doi.org/10.1007/s11936-024-01036-4

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