title: Ventricular tachycardia ablation remains treatment of last resort in structural heart disease: argument for earlier intervention.
abstract: BACKGROUND
  Despite advances in ablation of ventricular tachycardia (VT), recognized toxicity of amiodarone, and potential harm of implantable cardioverter defibrillator (ICD) shocks, there appears to be reluctance to pursue catheter ablation.
  
  
  RESULTS
  We tested the hypothesis that patients with structural heart disease and VT are referred late for ablation and may have worse outcomes as a result. Consecutive patients with VT and structural heart disease referred to a single center, between January 2008 and April 2009 were studied. Patients with prior VT ablations were excluded. Late referrals were defined as those with 2 or more episodes of VT, separated by at least 1 month. Ninety-eight consecutive patients were analyzed. Ninety-six percent of patients had an ICD implanted prior to ablation, 58% were in VT storm and 67% taking ≥400 mg daily of amiodarone or amiodarone intolerant (10%). Thirty-six patients fit the definition of early referral and 62 late. Overall acute procedural success was achieved in 89%. Amiodarone dose decreased from a mean and median of 559 and 400 mg daily preablation to 98 and 0 postablation (P < 0.01). Mean and median VT episodes decreased from 17 and 6 in the month preceding ablation to 1 and 0 in the 6 months following ablation (P < 0.01). In Kaplan-Meier analysis, the early referral group had superior 1-year VT free survival (P = 0.01).
  
  
  CONCLUSIONS
  VT ablation is frequently reserved for patients receiving recurrent ICD shocks despite high dose amiodarone. Stronger consideration should be given to earlier referral for VT ablation in patients with structural heart disease.
authors.affiliation: Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Frankel
authors.forename: Stavros E
authors.initials: SE
authors.lastname: Mountantonakis
authors.forename: Melissa R
authors.initials: MR
authors.lastname: Robinson
authors.forename: Erica S
authors.initials: ES
authors.lastname: Zado
authors.forename: David J
authors.initials: DJ
authors.lastname: Callans
authors.forename: Francis E
authors.initials: FE
authors.lastname: Marchlinski
mesh_terms: D000368:Aged; D000638:Amiodarone / Q000008:administration & dosage / Q000009:adverse effects; D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage / Q000009:adverse effects; D017115:Catheter Ablation / Q000009:adverse effects; D016009:Chi-Square Distribution; D017147:Defibrillators, Implantable; D018572:Disease-Free Survival; D005260:Female; D006331:Heart Diseases / Q000150:complications*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010414:Pennsylvania; D012017:Referral and Consultation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents; D000638:Amiodarone