VT-Ablation als Alternative zum Defibrillator: Wer ist ein Kandidat?

Zusammenfassung

Patienten mit struktureller Herzerkrankung sind besonders gefährdet, eine ventrikuläre Tachykardie (VT) zu erleiden, das Risiko für den plötzlichen Herztod (PHT) ist erhöht. Implantierbare Kardioverter-Defibrillatoren (ICD) sind zur Prävention des PHT seit mehr als 20 Jahren in der Primär- und Sekundärprophylaxe empfohlen, wobei in der Sekundärprophylaxe die linksventrikuläre Ejektionsfraktion (LVEF) keine Rolle spielt. Ein Patient mit einer LVEF von > 35% und hämodynamisch tolerierter VT scheint ein Kandidat zu sein, der von einer primären Strategie der Katheterablation (KA) profitiert, ohne dass sofort ein ICD als „Reserve“ benötigt wird.

Abstract

Patients with structural heart disease are at risk of experiencing ventricular tachycardia (VT), and the risk of sudden cardiac death (SCD) is increased. Implantable cardioverter defibrillators (ICD) have been recommended for primary and secondary prevention of SCD for more than 20 years, and left ventricular ejection fraction (LVEF) plays no role in secondary prevention. A patient with an LVEF of > 35% and hemodynamically tolerated ventricular tachycardia (VT) appears to be a candidate who may benefit from a primary catheter ablation (CA) strategy without the immediate need for an ICD as a “backup.”

Was ist wichtig?

Patienten nach einem Myokardinfarkt mit einer linksventrikulären Ejektionsfraktion (LVEF) von > 35%, hämodynamisch tolerierter ventrikulärer Tachykardie (VT) und Nichtinduzierbarkeit nach Katheterablation (KA) haben eine ausgezeichnete Prognose, die einen Verzicht der ICD-Implantation (ICD: implantierbarer Kardioverter-Defibrillator) rechtfertigen kann [1]. Die technischen Entwicklungen in der Elektrophysiologie, die bei der KA von VT im Einzelfall eine Kombination aus hochauflösendem anatomischem und funktionellem Substratmap erlauben, ermöglichen die individuelle Identifizierung von Narbenarealen, die mit dem Wiederauftreten von VT im Zusammenhang stehen, sodass VT-Rezidive effizient verhindert und unnötige ICD-Implantationen vermieden werden können.

Schlüsselwörter

Alternative - VT-Ablation - ICD-Implantation

Keywords

alternative - VT ablation - ICD implantation

Publikationsverlauf

Artikel online veröffentlicht:
08. Oktober 2025

• Literatur

• 1 Rademaker R, de Riva M, Piers RD. et al. Excellent Outcomes After First-Line Ablation in Post-MI Patients With Tolerated VT and LVEF > 35%. JACC Clin Electrophysiol 2024; 10: 2303-2311
• 2 Zeppenfeld K, Tfelt-Hansen J, de Riva M. et al. 2022 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43: 3997-4126
• 3 Kuck KH, Cappato R, Siebels J. et al. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: the Cardiac Arrest Study Hamburg (CASH). Circulation 2000; 102: 748-754
• 4 Klein RC, Raitt MH, Wilkoff BL. et al. Analysis of implantable cardioverter defibrillator therapy in the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial. J Cardiovasc Electrophysiol 2003; 14: 940-948
• 5 Connolly SJ, Gent M, Roberts RS. et al. Canadian implantable defibrillator study (CIDS): a randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation 2000; 101: 1297-1302
• 6 Boecker D, Block M, Isbruch F. et al. Benefits of treatment with implantable cardioverter defibrillators in patients with stable ventricular tachycardia without cardiac arrest. Br Heart J 1995; 73: 158-163
• 7 Raitt MH, Renfroe EG, Epstein AE. et al. “Stable” ventricular tachycardia is not a benign rhythm: insights from the antiarrhythmics versus implantable defibrillators (AVID) registry. Circulation 2001; 103: 244-252
• 8 Glikson M, Lipchenca I, Viskin S. et al. Long-term outcome of patients who received implantable cardioverter defibrillators for stable ventricular tachycardia. J Cardiovasc Electrophysiol 2004; 15: 658-664
• 9 Clemens M, Peichl P, Wichterle D. et al. Catheter ablation of ventricular tachycardia as the first-line therapy in patients with coronary artery disease and preserved left ventricular systolic function: long-term results. J Cardiovasc Electrophysiol 2015; 26: 1105-1110
• 10 Domanski MJ, Sakseena S, Epstein AE. et al. Relative effectiveness of the implantable cardioverter-defibrillator and antiarrhythmic drugs in patients with varying degrees of left ventricular dysfunction who have survived malignant ventricular arrhythmias. J Am Coll Cardiol 1999; 34: 1090-1095
• 11 Bianchi S, Cauti FM. Ablation of ventricular tachycardia in 2021. Eur Heart J Suppl 2021; 23(Suppl. E): E25-E27
• 12 Klein H, Karp RB, Kouchoukos NT. et al. Intraoperative electrophysiologic mapping of the ventricles during sinus rhythm in patients with a previous myocardial infarction. Identification of the electrophysiologic substrate of ventricular arrhythmias. Circulation 1982; 66: 847-853
• 13 Bourier F, Busch S, Sommer P. et al. Katheterablation ventrikulärer Tachykardien bei Patienten mit ischämischer Kardiomyopathie. Herzschr Elektrophysiol 2022; 33: 88-97
• 14 Natale A, Zeppenfeld K, Della Bella P. et al. Twenty-five years of catheter ablation of ventricular tachycardia: a look back and a look forward. Europace 2023; 25: euad225
• 15 Vázquez-Calvo S, Roca-Luque I, Porta Sánchez A. Ventricular tachycardia ablation guided by functional substrate mapping: practices and outcomes. J Cardiovasc Dev Dis 2022; 9: 288
• 16 Marchlinski FE, Callans DJ, Gottlieb CD. et al. Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy. Circulation 2000; 101: 1288-1296
• 17 Roca-Luque I, Quinto L, Sanchez-Somonte P. et al. Late potential abolition in ventricular tachycardia ablation. Am J Cardiol 2022; 174: 53-60
• 18 Jaïs P, Maury P, Khairy P. et al. Elimination of local abnormal ventricular activities. Circulation 2012; 125: 2184-2196
• 19 Aziz Z, Shatz D, Raiman M. et al. Targeted ablation of ventricular tachycardia guided by wavefront discontinuities during sinus rhythm. Circulation 2019; 140: 1383-1397
• 20 Porta-Sánchez A, Jackson N, Lukac P. et al. Multicenter study of ischemic ventricular tachycardia ablation with decrement-evoked potential (DEEP) mapping with extra stimulus. JACC Clin Electrophysiol 2018; 4: 307-315
• 21 Acosta J, Andreu D, Penela D. et al. Elucidation of hidden slow conduction by double ventricular extrastimuli: a method for further arrhythmic substrate identification in ventricular tachycardia ablation procedures. Europace 2018; 20: 337-346
• 22 Guichard JB, Regany-Closa M, Vázquez-Calvo S. et al. Substrate Mapping for Ventricular Tachycardia Ablation Through High-Density Whole-Chamber Double Extra Stimuli: The S3 Protocol. JACC Clin Electrophysiol 2024; 10: 1534-1547
• 23 Mayer J, Al-Sheikhli J, Niespialowska-Steuden M. et al. Detailed analysis of electrogram peak frequency to guide ventricular tachycardia substrate mapping. Europace 2024; 26: euae253
• 24 Kuck KH, Schaumann A, Eckardt L. VTACH study group. et al. Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial. Lancet 2010; 375: 31-40
• 25 Reddy VY, Reynolds MR, Neuzil P. et al. Prophylactic catheter ablation for the prevention of defibrillator therapy. N Engl J Med 2007; 357: 2657-2665
• 26 Freedenberg V, Thomas SA, Friedmann E. Anxiety and depression in implanted cardioverter defibrillator recipients and heart failure: a review. Heart Fail Clin 2011; 7: 59-68
• 27 Sohail MR, Henrikson CA, Braid-Forbes MJ. et al. Mortality and cost associated with cardiovascular implantable electronic device infections. Arch Intern Med 2011; 171: 1821-1828
• 28 Al-Gobari M, Al-Aqeel S, Gueyffier F. et al. Effectiveness of drug interventions to prevent sudden cardiac death in patients with heart failure and reduced ejection fraction: an overview of systematic reviews. BMJ Open 2018; 8: e021108
• 29 Pauriah M, Cismaru G, Magnin-Poull I. et al. A stepwise approach to the management of postinfarct ventricular tachycardia using catheter ablation as the first-line treatment: a single-center experience. Circ Arrhythm Electrophysiol 2013; 6: 351-356
• 30 Maury P, Baratto F, Zeppenfeld K. et al. Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%. Eur Heart J 2014; 35: 1479-1485
• 31 Askarinejad A, Arya A, Zangiabadian M. et al. Catheter ablation as first-line treatment for ventricular tachycardia in patients with structural heart disease and preserved left ventricular ejection fraction: a systematic review and meta-analysis. Sci Rep 2024; 14: 18536
• 32 Eckardt L, Doldi F, Anwar O. et al. Major in-hospital complications after catheter ablation of cardiac arrhythmias: individual case analysis of 43 031 procedures. Europace 2024; 26: 1-12