Katheterablation ventrikulärer Tachykardien

Abstract

Due to substantial progress in mapping and ablation strategies and tremandeous improvement of catheter and navigation technologies catheter ablation of ventricular tachycardias (VT) has become a standard first-line therapy of a broad spectrum of idiopathic VTs, VTs due to structural heart disease and even of ventricular fibrillation.

Aims of VT ablation are suppression of symptoms, prevention of ICD therapies and improvement of prognosis.

The 12-lead ECG is still one of the most important diagnostic tools to differentiate supraventricular from ventricular tachycardias and to plan adequate mapping and ablation approaches. However, a thoroughly conducted diagnostic work-up to identify a possible coexisting structural heart disease is inevitable (e. g. echocardiography, MRI – including delayed enhancement MRI and coronary angiography).

Antiarrhythmic drugs are often of limited success due to a lower efficacy and higher rate of adverse events. The basic mechanism of focal VTs is local automaticity or micro-reentry, which can be targeted by finding the earliest local activation. The strategy of treating macro-reentry VTs is to define the VT circuit including exit, entry and isthmus or to ablate all pathological local electrograms within low-voltage or scar areas.

Possible endpoints of VT ablation procedures are VT termination during ablation, non-inducibility at the end of the procedure and elimination of all „late potentials“ within the „area of interest“. Epicardial mapping and ablation approaches can be highly demanding and should be restricted to experienced operators and EP centers.

Possible complications of VT ablation procedures are thromboembolism (including strokes), injury of cardiac anatomic structures like mitral- and aortic valve, coronary vessels or the specific cardiac conduction system. Procedure-related mortality is reported to reach 3 %.

Recently updated guidelines provide detailed diagnostic and treatment algorithms for the management of VTs.

Kernaussagen

• Diagnostisch relevant sind VT-EKG und Dokumentation einer zugrunde liegenden Herzerkrankung.

• Bei Patienten mit dokumentierten VTs ist eine dedizierte Aufarbeitung erforderlich, um eine mögliche prognostische Relevanz zu identifizieren.

• Die Katheterablation sollte frühzeitig als Therapiekonzept an erfahrenen Zentren durchgeführt werden.

• Die möglichen Strategien der Katheterablation zur Therapie von VTs reichen von fokal limitiert (vor allem bei fokalem VT-Mechanismus) bis zu komplexen endo- und epikardialen substratbasierten Modifikationen (bei VT im Rahmen einer NICM).

• Die konkrete Ablationsstrategie hängt vom zugrunde liegenden Mechanismus der VT, der hämodynamischen Tolerabilität und der zugrunde liegenden Herzerkrankung ab.

• Die Erfolgsraten der Katheterablation sind bei erfahrenen Untersuchern hoch und die Komplikationsraten gering.

• Eine Katheterablation bei Patienten mit unaufhörlichen VTs oder im elektrischen Sturm kann vital relevant sein und sollte in kooperierende Netzwerke eingebunden werden.

• Literatur

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