Adjunctive Interventional Techniques When Percutaneous Catheter Ablation for Drug Refractory Ventricular Arrhythmias Fail
A Contemporary Review
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Percutaneous catheter ablation is a key treatment modality in the contemporary management of ventricular arrhythmias (VA). Ablation reduces the burden of implanted cardioverter-defibrillator shocks,1 which are otherwise associated with poor quality of life and increased mortality.2 Ablation can be life saving for incessant or repeated VA electrical storm (ES).3 However, acute and long-term efficacy remain suboptimal. Acute procedural success is achievable in 56% to 77% of patients with ventricular tachycardia (VT) related to ischemic cardiomyopathy and 38% to 67% of patients with nonischemic cardiomyopathy (NICM), whereas 30% to 50% of patients recur during long-term follow-up.4–6 Exhaustive efforts using endocardial and epicardial ablation at times fail to abolish VA. Such patients suffer a poor prognosis from uncontrollable arrhythmia, progressive heart failure, and high mortality.1 As the utilization of VT ablation continues to increase over time, the complexity of patients being referred for ablation may also increase. It is likely that an increasing number of patients will be encountered in whom standard ablation approaches will fail. Thus, the focus of this contemporary review is to address the reasons for failure of catheter ablation of VA with contemporary techniques and to summarize the published literature on alternative interventional approaches for the treatment of VA. It must be emphasized that the management of such patients is best undertaken within a dedicated unit for the treatment of complex VA, where there is a strong clinical collaboration between electrophysiologists, interventional cardiologists, anesthesiologists, advanced heart failure physicians, and cardiac surgeons.7 It is important to emphasize that this review outlines the more aggressive spectrum of alternative interventional approaches described in the literature, which are less well studied that conventional endocardial (or epicardial) ablation. For the majority of patients who fail initial ablation attempts, a repeat standard procedure is warranted. Often …