2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary

Abstract

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Keywords: Catheter ablation; Clinical document; Electrical storm; Electroanatomical mapping; Electrocardiogram; Expert consensus statement; Imaging; Premature ventricular complex; Radiofrequency ablation; Ventricular arrhythmia; Ventricular tachycardia.

Figure 1

Monomorphic (A), pleomorphic (B), and polymorphic (C) VT. Reproduced with permission of the Heart Rhythm Society from Aliot et al. EHRA/HRS expert consensus on catheter ablation of ventricular arrhythmias. Heart Rhythm 2009;6:886–933. VT = ventricular tachycardia.

Figure 2

Congenital heart disease and sustained VT. For further discussion of ICD candidacy, please see PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease (S4.7.14) and 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities (S4.7.26). ACA = aborted cardiac arrest; CHD = congenital heart disease; DORV = double outlet right ventricle; ICD = implantable cardioverter defibrillator; TOF = tetralogy of Fallot; VT = ventricular tachycardia.

Figure 3

Examples of 12-lead ECGs of premature ventricular complexes from different LV sites, as corroborated by successful focal ablation. (A) shows 12-lead ECG patterns of common ventricular arrhythmia origins in patients without SHD [1–9] from the left ventricle. All leads are displayed at the same amplification and sweep speed. These locations are illustrated in (B) based on 3D reconstruction of a cardiac computed tomography using the MUSIC software that was developed at the University of Bordeaux. The reconstruction shows an anterolateral view of the left ventricle, aorta, and left atrium. Also shown are the coronary arteries (red), the coronary venous system (blue), and the phrenic nerve (green). AIV = anterior interventricular vein; AL PAP = anterolateral papillary muscle; AMC = aortomitral continuity; ECG = electrocardiogram; GCV = great cardiac vein; ant. MA = anterior mitral valve annulus; PM PAP = posteromedial papillary muscle; R/L = right-left; SHD = structural heart disease; SoV = sinus of Valsalva.

Figure 4

Examples of 12-lead ECGs of premature ventricular complexes from different right ventricular sites, as corroborated by successful focal ablation. All leads are displayed at the same amplification and sweep speed. (A) shows the 12-lead ECG pattern of common origins of right ventricular arrhythmias in patients without SHD [1–6]. The locations are detailed in a 3D reconstruction of the computed tomography using the MUSIC software that was developed at the University of Bordeaux. The reconstruction shown in (B) illustrates the septal view of the right ventricle. Indicated are the pulmonary artery, the tricuspid valve annulus, and the right ventricular apex. ECG = electrocardiogram; PA = pulmonary artery; RVOT= right ventricular outflow tract; SHD = structural heart disease; TVA = tricuspid valve annulus.

Figure 5

Entrainment responses from components of reentrant VT circuit. CL = cycle length; PPI = postpacing interval; VT = ventricular tachycardia. Adapted with permission from Elsevier (Stevenson et al. J Am Coll Cardiol 1997;29:1180–1189).

Figure 6

Pacing from the protected isthmus of a VT circuit. Entrainment mapping during VT. The VT CL is 620 ms, and pacing is performed at a CL of 580 ms. A low-voltage electrogram is located in diastole on the recordings of the ablation catheter (Map). The stimulus-QRS interval is 230 ms and matches with the electrogram-QRS interval. The postpacing interval is equal to the VT CL. The stimulus-QRS/VT CL ratio is 0.37, indicating that the catheter is located in the common pathway. CL = cycle length; PPI = postpacing interval; VT = ventricular tachycardia.

Figure 7

Anatomical boundaries of the LV summit, with the inaccessible [1] and accessible [2] parts. Shown are the left anterior descending artery (LAD), the circumflex artery (Cx), the great cardiac vein (GCV), the anterior interventricular vein (AIV), and the first and second diagonal branch of the LAD (D1, D2).

Figure 8

Intraprocedural imaging during ablation of papillary muscle arrhythmias. (A): Anatomical map of the left ventricle (CARTO, Biosense Webster) showing contact of the ablation catheter (Abl) with the posteromedial papillary muscle (PMPAP). (B): Intracardiac echocardiogram showing real-time visualization of the ablation catheter during ablation on the anterolateral papillary muscle (ALPAP).

Figure 9

Overview of the workflow for catheter ablation of VT in patients with IHD. Not all of these steps might be required, and steps can be performed in a different sequence. For instance, repeat VT induction can be deferred in patients with hemodynamic instability. In addition, the operator might have to adapt to events that arise during the case, for instance, to take advantage of spontaneous initiation of stable VT during substrate mapping and switch to activation mapping. IHD = ischemic heart disease; PES = programmed electrical stimulation; SR = sinus rhythm; VT = ventricular tachycardia.

Figure 10

Epicardial substrate ablation in a patient with Brugada syndrome and appropriate ICD shocks for VF. Image integration of a preacquired CT with the electroanatomical epicardial substrate map is shown in (A). Purple represents bipolar voltage >1.5 mV. Fractionated potentials (arrows) are tagged with black dots, and a representative example is displayed. Widespread fractionated potentials were recorded from the epicardial aspect of the RVOT extending down into the basal RV body. Ablation lesions are tagged with red dots. Some fractionated potentials could not be ablated due to the proximity of the acute marginal branches of the right coronary artery. Panel (B) shows the significant transient accentuation of the Brugada ECG pattern during the application of radiofrequency energy at one of these sites. CT = computed tomography; ECG = electrocardiogram; ICD = implantable cardioverter defibrillator; PA = pulmonary artery; RA = right atrium; RCA = right coronary artery; RFA = radiofrequency ablation; RV = right ventricle; RVOT = right ventricular outflow tract; VF = ventricular fibrillation.

Figure 11

Right ventricular voltage maps from cases of moderate (upper row) and advanced (lower row) arrhythmogenic right ventricular cardiomyopathy (ARVC) are shown. Purple represents a voltage >1.5 mV in the bipolar maps (left and right) and >5.5 mV in the unipolar maps (center); red represents a voltage <0.5 mV in the bipolar maps and <3.5 mV in the unipolar maps. Moderate ARVC is defined as having a bipolar/unipolar low-voltage area ratio of <0.23 and is associated with epicardial arrhythmogenic substrate area (ASA) (defined by the presence of electrograms with delayed components of >10 cm². Advanced ARVC displays a bipolar/unipolar endocardial low-voltage area of ≥0.23, which is associated with an epicardial arrhythmogenic substrate area of ≤10 cm². Adapted with permission from Oxford University Press (Berruezo et al. Europace 2017;19:607–616).

Figure 12

Anatomical isthmuses (AI) in repaired tetralogy of Fallot according to the surgical approach and variation of the malformation. RV = right ventricular; TA = tricuspid annulus; VSD = ventricular septal defect.

Figure 13

Factors influencing outcomes post VA ablation. ICD = implantable cardioverter defibrillator; LVAD = left ventricular assist device; VA = ventricular arrhythmia; VT = ventricular tachycardia.