Role of alternative interventional procedures when endo- and epicardial catheter ablation attempts for ventricular arrhythmias fail.
BACKGROUND
Ventricular tachycardia (VT) refractory to antiarrhythmic drugs and standard percutaneous catheter ablation techniques portends a poor prognosis. We characterized the reasons for ablation failure and describe alternative interventional procedures in this high-risk group.


RESULTS
Sixty-seven patients with VT refractory to 4±2 antiarrhythmic drugs and 2±1 previous endocardial/epicardial catheter ablation attempts underwent transcoronary ethanol ablation, surgical epicardial window (Epi-window), or surgical cryoablation (OR-Cryo; age, 62±11 years; VT storm in 52%). Failure of endo/epicardial ablation attempts was because of VT of intramural origin (35 patients), nonendocardial origin with prohibitive epicardial access because of pericardial adhesions (16), and anatomic barriers to ablation (8). In 8 patients, VT was of nonendocardial origin with a coexisting condition also requiring cardiac surgery. Transcoronary ethanol ablation alone was attempted in 37 patients, OR-Cryo alone in 21 patients, and a combination of transcoronary ethanol ablation and OR-Cryo (5 patients), or transcoronary ethanol ablation and Epi-window (4 patients), in the remainder. Overall, alternative interventional procedures abolished ≥1 inducible VT and terminated storm in 69% and 74% of patients, respectively, although 25% of patients had at least 1 complication. By 6 months post procedures, there was a significant reduction in defibrillator shocks (from a median of 8 per month to 1; P<0.001) and antiarrhythmic drug requirement although 55% of patients had at least 1 VT recurrence, and mortality was 17%.


CONCLUSIONS
A collaborative strategy of alternative interventional procedures offers the possibility of achieving arrhythmia control in high-risk patients with VT that is otherwise uncontrollable with antiarrhythmic drugs and standard percutaneous catheter ablation techniques.
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA. utedrow@partners.org saurabh.kumar@mh.org.au.
Saurabh
S
Kumar
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Chirag R
CR
Barbhaiya
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Piotr
P
Sobieszczyk
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Andrew C
AC
Eisenhauer
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Gregory S
GS
Couper
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Koichi
K
Nagashima
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Saagar
S
Mahida
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Samuel H
SH
Baldinger
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Eue-Keun
EK
Choi
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Laurence M
LM
Epstein
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Bruce A
BA
Koplan
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Roy M
RM
John
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
Gregory F
GF
Michaud
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA.
William G
WG
Stevenson
From the Arrhythmia Unit (S.K., C.R.B., K.N., S.M., S.H.B., E.-K.C., L.M.E., B.A.K., R.M.J., G.F.M., W.G.S., U.B.T.), Interventional Cardiology and Vascular Medicine, Cardiovascular Division (P.S., A.C.E.), and Division of Cardiac Surgery (G.S.C.), Brigham and Women's Hospital, Boston, MA. utedrow@partners.org saurabh.kumar@mh.org.au.
Usha B
UB
Tedrow
D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D003452:Cryosurgery / Q000009:adverse effects; D000431:Ethanol / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000503:physiopathology / Q000601:surgery*; D012086:Reoperation; D012307:Risk Factors; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D017211:Treatment Failure
D000889:Anti-Arrhythmia Agents; D000431:Ethanol
catheter ablation; surgery; tachycardia, ventricular