Management of Ventricular Arrhythmias in Heart Failure

• Published in: Current heart failure reports Vol. 20; no. 4; pp. 237 - 253
• Main Authors: Vázquez-Calvo, Sara, Roca-Luque, Ivo, Althoff, Till F.
• Format: Journal Article
• Language: English
• Published: New York Springer US 01-08-2023
• Subjects: Anti-Arrhythmia Agents - therapeutic use; Arrhythmias, Cardiac - etiology; Arrhythmias, Cardiac - therapy; Cardiac Surgery; Cardiology; Catheter Ablation - methods; Death, Sudden, Cardiac - etiology; Death, Sudden, Cardiac - prevention & control; Defibrillators, Implantable - adverse effects; Heart Failure - drug therapy; Heart Failure - therapy; Humans; Imaging; Internal Medicine; Medicine; Medicine & Public Health; Radiology; Topical Collection on Devices; Vascular Surgery; Heart failure; Ventricular tachycardia; Sudden cardiac death; Catheter ablation; Imaging; Cardiac implantable electronic devices
• ISSN: 1546-9530; 1546-9549; 1546-9549
• DOI: 10.1007/s11897-023-00608-y

Purpose of Review
Despite substantial progress in medical and device-based heart failure (HF) therapy, ventricular arrhythmias (VA) and sudden cardiac death (SCD) remain a major challenge. Here we review contemporary management of VA in the context of HF with one particular focus on recent advances in imaging and catheter ablation.
Recent Findings
Besides limited efficacy of antiarrhythmic drugs (AADs), their potentially life-threatening side effects are increasingly acknowledged. On the other hand, with tremendous advances in catheter technology, electroanatomical mapping, imaging, and understanding of arrhythmia mechanisms, catheter ablation has evolved into a safe, efficacious therapy. In fact, recent randomized trials support early catheter ablation, demonstrating superiority over AAD. Importantly, CMR imaging with gadolinium contrast has emerged as a central tool for the management of VA complicating HF: CMR is not only essential for an accurate diagnosis of the underlying entity and subsequent treatment decisions, but also improves risk stratification for SCD prevention and patient selection for ICD therapy. Finally, 3-dimensional characterization of arrhythmogenic substrate by CMR and imaging-guided ablation approaches substantially enhance procedural safety and efficacy.
Summary
VA management in HF patients is highly complex and should be addressed in a multidisciplinary approach, preferably at specialized centers. While recent evidence supports early catheter ablation of VA, an impact on mortality remains to be demonstrated. Moreover, risk stratification for ICD therapy may have to be reconsidered, taking into account imaging, genetic testing, and other parameters beyond left ventricular function.