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.

/pdf/2019-hrs-ehra-aphrs-lahrs-expert-consensus-statement-on-3p2ufvqfaj.pdf

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias.

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

Background— Radiofrequency ablation (RFA) of ventricular tachycardia (VT) can fail because of inaccessibility to the VT substrate. Transarterial coronary ethanol ablation can be effective but entails arterial instrumentation risk. We hypothesized that retrograde coronary venous ethanol ablation can be an alternative bail-out approach to failed VT RFA.

Methods and Results— Out of 334 consecutive patients undergoing VT/premature ventricular contraction ablation, 7 patients underwent retrograde coronary venous ethanol ablation. Six out of 7 patients had failed RFA attempts (including epicardial in 3). Coronary venogram-guided venous mapping was performed using a 4F quadripolar catheter or an alligator-clip–connected angioplasty wire. Targeted veins included those with early presystolic potentials and pace-maps matching VT/premature ventricular contraction. An angioplasty balloon (1.5–2×6 mm) was used to deliver 1 to 4 cc of 98% ethanol into a septal branch of the anterior interventricular vein in 5 patients with left ventricular summit VT, a septal branch of the middle cardiac vein, and a posterolateral coronary vein (n=1 each). The clinical VT was successfully ablated acutely in all patients. There were no complications of retrograde coronary venous ethanol ablation, but 1 patient developed pericardial and pleural effusion attributed to pericardial instrumentation. On follow-up of 590±722 days, VT recurred in 4 out of 7 patients, 3 of whom were successfully reablated with RFA.

Conclusions— Retrograde coronary venous ethanol ablation is safe and feasible as a bail-out approach to failed VT RFA, particularly those originating from the left ventricular summit.

Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Ventricular Tachycardia.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/joa3.12185

/pdf/2019-hrs-ehra-aphrs-lahrs-expert-consensus-statement-on-1h5fxx2ofd.pdf

Saline Enhanced Radiofrequency Ablation
Background

Radiofrequency (RF) ablation of scar-mediated ventricular tachycardia is limited by the size of lesions achieved with conventional catheters. We examined the gross and histopathology characteristics of warm saline-enhanced radiofrequency (SERF) ablation delivered to left ventricular (LV) infarction scars via a novel catheter employing an extendable infusion needle electrode.



Methods and Results

Yorkshire pigs (n = 14) underwent LV infarction by left anterior descending artery balloon occlusion. After 4–6 weeks, baseline hemodynamic data were obtained and endocardial electroanatomic mapping was performed in 13 surviving animals. Following single, 40 Watt SERF ablations delivered endocardially to the center of infarctions, 4 were examined the same day (day 0). The rest underwent repeat measurements and were sacrificed at 1 week (n = 6), and at 4 weeks (n = 3). Average lesion depth and diameter were: 1.85 ± 0.7 cm and 2.33 ± 0.7 cm at day 0, 0.91 ± 0.1 cm and 1.9 ± 0.4 cm after 1 week, and 1.0 ± 0.2 cm and 1.89 ± 0.76 cm after 4 weeks, respectively. Histopathology at 1 week showed that ablation lesions covered 41 ± 10.6% of the infarct area. SERF ablation lesions extended 100%, 90%, and 68% of the total wall thickness at day 0, 1 week, and 4 weeks, respectively. Hemodynamic parameters were unchanged. There were no myocardial wall perforations or aneurysms.



Conclusion

SERF ablation within myocardial infarct tissue produced large, near-transmural lesions, without evidence of myocardial perforation, wall thinning, or aneurysm formation. Ablations did not produce any negative hemodynamic effects in this small group of experiments.

Characterization of Warm Saline‐Enhanced Radiofrequency Ablation Lesions in the Infarcted Porcine Ventricular Myocardium

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Characterization of Warm Saline‐Enhanced Radiofrequency Ablation Lesions in the Infarcted Porcine Ventricular Myocardium