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arrhythmias
Complex ventricular arrhythmias: a therapeutic nightmare
  1. Antonio Berruezo
  1. Correspondence to Dr Antonio Berruezo, Thorax Institute, Hospital Clínic, University of Barcelona, Cardiology Department – Arrhythmia Section, Villarroel 170, 08036 Barcelona, Catalonia, Spain; berruezo{at}clinic.ub.es

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The ventricular tachycardia (VT) catheter ablation procedure has evolved substantially in recent years. Progress in the field permits effective treatment of complex ventricular arrhythmias previously not amenable to catheter ablation.

Catheter ablation is now indicated for many patients with multiple VT morphologies, non-tolerated and non-sustained VTs that had been previously considered unmappable. Advances in mapping/ablation technology, including new energy sources for ablation and both contact and non-contact mapping systems, have been key to extending indications and improving outcomes.1 2 There is also increasing interest in pre-procedural and intra-procedural cardiac imaging techniques, such as intracardiac echocardiography (ICE), contrast enhanced cardiac magnetic resonance (CE-CMR), contrast enhanced multidetector CT (CE-MDCT) or positron emission tomography (PET-CT). These techniques can provide both anatomic and scar location/extent information. Although no trial data have shown that imaging can improve VT ablation results, its use is widely accepted in clinical practice (figure 1).

Figure 1

The heart of a 31-year-old woman, highly symptomatic with repetitive palpitations despite antiarrhythmic drugs and a previously failed ablation attempt from the right ventricular outflow tract. Before the procedure, a contrast enhanced multidetector computed tomography (CE-MDCT) was performed and segmented anatomy was registered with the three dimensional electroanatomic map obtained with the CARTO system. Colour coded activation maps (higher precocity in red) during premature ventricular beats, projected in the mapped chambers/structures, are shown (A–F). (A) Left lateral view of the right ventricle and coronary sinus. Coronary sinus is mapped up to the proximal portion of the anterior interventricular vein. Note that the earliest electrogram is registered at the distal coronary sinus. (B) Same view, adding the mapped aortic root. Precocity continues to be higher in the distal coronary sinus. (C) Same view, adding the left ventricle. Electrograms at the left ventricular outflow tract are registered late as compared with the coronary sinus. (D) …

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