title: Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy.
abstract: OBJECTIVE
  We report on the initiation of ventricular fibrillation (VF) storm in patients with ischemic cardiomyopathy (ICM) and the results of targeted ablation to treat VF storm.
  
  
  BACKGROUND
  Monomorphic premature ventricular contractions (PVCs) have been shown to initiate VF in patients without structural heart disease.
  
  
  METHODS
  A total of 29 patients with ICM and documented VF initiation were identified. In 21 patients, VF storm was controlled with antiarrhythmic drugs and/or treatment of heart failure. Eight patients with VF (mean 52 +/- 25 episodes) refractory to medical management required ablation. All patients underwent three-dimensional electroanatomical mapping using CARTO (Biosense-Webster Inc., Diamond Bar, California), and PVCs were mapped when present. Scarred areas were identified using voltage mapping.
  
  
  RESULTS
  Monomorphic PVCs initiated VF in all 29 identified patients. Five of eight patients requiring ablation had frequent PVCs that allowed PVC mapping. The earliest activation site was consistently located in the scar border zone. The PVCs were always preceded by a Purkinje-like potential (PLP). Ablation was successfully performed at these sites. In three patients, infrequent PVCs prevented mapping, but PLPs were recorded around the scar border. Ablation targeting these potentials along the scar border was successfully performed. During follow-up (10 +/- 6 months), one patient had a single VF episode and another developed sustained, monomorphic ventricular tachycardia. There was no recurrence of VF storm.
  
  
  CONCLUSIONS
  Ventricular fibrillation in ICM is triggered by monomorphic PVCs originating from the scar border zone with preceding PLPs; targeting these PVCs may prevent VF recurrence. In the absence of PVCs, both substrate mapping and ablation appear to be equally effective.
authors.affiliation: Section of Cardiovascular Electrophysiology, Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Nassir F
authors.initials: NF
authors.lastname: Marrouche
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: Oussama
authors.initials: O
authors.lastname: Wazni
authors.forename: Robert
authors.initials: R
authors.lastname: Schweikert
authors.forename: David O
authors.initials: DO
authors.lastname: Martin
authors.forename: Walid
authors.initials: W
authors.lastname: Saliba
authors.forename: Fethi
authors.initials: F
authors.lastname: Kilicaslan
authors.forename: Jennifer
authors.initials: J
authors.lastname: Cummings
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.forename: Mandeep
authors.initials: M
authors.lastname: Bhargava
authors.forename: Dianna
authors.initials: D
authors.lastname: Bash
authors.forename: Johannes
authors.initials: J
authors.lastname: Brachmann
authors.forename: Jens
authors.initials: J
authors.lastname: Guenther
authors.forename: Steven
authors.initials: S
authors.lastname: Hao
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.forename: Antonio
authors.initials: A
authors.lastname: Rossillo
authors.forename: Antonio
authors.initials: A
authors.lastname: Raviele
authors.forename: Sakis
authors.initials: S
authors.lastname: Themistoclakis
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D018780:Body Surface Potential Mapping; D009202:Cardiomyopathies / Q000503:physiopathology / Q000628:therapy*; D017115:Catheter Ablation; D017147:Defibrillators, Implantable; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009200:Myocardial Contraction / Q000502:physiology; D017202:Myocardial Ischemia / Q000503:physiopathology / Q000628:therapy*; D013318:Stroke Volume / Q000502:physiology; D016896:Treatment Outcome; D014693:Ventricular Fibrillation / Q000503:physiopathology / Q000628:therapy*
chemical_list: D000889:Anti-Arrhythmia Agents