Role of Alternative Interventional Procedures When Endo- and Epicardial Catheter Ablation Attempts for Ventricular Arrhythmias Fail

• Published in: Circulation. Arrhythmia and electrophysiology Vol. 8; no. 3; pp. 606 - 615
• Main Authors: Kumar, Saurabh, Barbhaiya, Chirag R, Sobieszczyk, Piotr, Eisenhauer, Andrew C, Couper, Gregory S, Nagashima, Koichi, Mahida, Saagar, Baldinger, Samuel H, Choi, Eue-Keun, Epstein, Laurence M, Koplan, Bruce A, John, Roy M, Michaud, Gregory F, Stevenson, William G, Tedrow, Usha B
• Format: Journal Article
• Language: English
• Published: United States American Heart Association, Inc 01-06-2015
• Subjects: Aged; Anti-Arrhythmia Agents - therapeutic use; Catheter Ablation - adverse effects; Catheter Ablation - methods; Cryosurgery - adverse effects; Ethanol - administration & dosage; Ethanol - adverse effects; Female; Humans; Male; Middle Aged; Pericardium - physiopathology; Pericardium - surgery; Reoperation; Risk Factors; Tachycardia, Ventricular - diagnosis; Tachycardia, Ventricular - physiopathology; Tachycardia, Ventricular - therapy; Time Factors; Treatment Failure; catheter ablation; tachycardia, ventricular; surgery
• ISSN: 1941-3149; 1941-3084
• DOI: 10.1161/CIRCEP.114.002522

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.