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Epicardial ablation as a bailout in electrical storm?

Epikardiale Ablation als Notfallversorgung bei Patienten mit elektrischem Sturm?

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Abstract

Electrical storm (ES) is one of the most challenging clinical scenarios facing electrophysiologists, and in certain settings emergency ablation should be performed. The majority of ES occurs in patients with structural heart disease, predominantly coronary heart disease and nonischemic heart disease like right ventricular arrhythmogenic dysplasia and previous myocarditis as well as other cardiomyopathies. Implantable cardioverter-defibrillators (ICDs) are the first-line therapy in patients with ventricular tachycardia (VT) and structural heart disease. Recurrent VT episodes or ES are major problems in patients who receive an ICD after a spontaneous sustained VT. In addition, in patients with an ICD implanted for primary prevention of sudden cardiac death, 20 % will experience at least one VT episode within 3–5 years after ICD implantation. Catheter ablation has a high success rate in the acute setting in eliminating clinical VT. However, several factors make enodocardial catheter ablation of VT more difficult especially in advanced ischemic heart disease with heart failure and aneurysm. Frequently in nonischemic cardiomyopathies (NICM) there tends to be an epicardial and intramyocardial substrate where the critical VT zone can occasionally be epicardial or intramural in location. In some patients, an epicardial approach should be warranted first together with an endocardial approach or after failure of enodocardial ablation. Currently, the success rates of endocardial ablation in the acute setting are acceptable, but in the long term they are still not well defined. The purpose of this article is to highlight the importance of epicardial ablation as an alternative approach in controlling ES and to confirm the need for highly qualified centers to manage such challenging cases.

Zusammenfassung

Der elektrische Sturm (ES) stellt eine der größten klinischen Herausforderungen an die Elektrophysiologie dar und kann auch eine Notfallablation notwendig machen. Ein ES tritt überwiegend bei Patienten mit struktureller Herzkrankheit, insbesondere einer koronaren Herzkrankheit (ischämische Kardiomyopathie, ICM), auf. Aber auch bei nicht­ischämischen Kardiomyopathien, wie bei dilatativer Kardiomyopathie (DCM), rechtsvent­rikulärer Dysplasie (ARVCM) sowie stattgehabter Myokarditis, kann es zu einem ES kommen. Der implantierbare Kardioverter-Defibrillator (ICD) ist bei Patienten mit anhaltenden spontanen ventrikulären Tachykardien (VT) und struktureller Herzerkrankung als Erstlinientherapie anerkannt. Aber auch nach primär-prophylaktischer ICD-Implantation haben rund 20 % der Patienten innerhalb von 3 bis 5 Jahren mindestens eine VT-Episode. Die Katheterablation hat eine hohe akute Effektivität in der Elimination klinischer VTs. Insbesondere bei Patienten mit nichtischämischen Kardiomyopathien findet sich häufig ein epikardiales oder intramyokardiales Substrat mit kritischer Relevanz für den VT-Mechanismus, was die effektive endokardiale Ablation erschwert oder unmöglich macht. Eine epikardiale Ablationsstrategie sollte somit bei einzelnen Patienten im Rahmen der ersten Ablationsprozedur (primär endo- und epikardial), oder aber nach ineffektiver vorhergehender endokardialer Ablation erwogen werden. Die Akuterfolge der endokardialen Ablation bei ES sind akzeptabel, langfristige Erfolge wurden jedoch bisher wenig beschrieben. Eine ausgedehnte Ablation (aller Regionen mit pathologischen ventrikulären Elektrogrammen) beinhaltet auch eine Expansion der Ablation auf epikardiale Bereiche. Der vorliegende Artikel fokussiert auf die Notwendigkeit und Effektivität der epikardialen Ablation im Rahmen der interventionellen Therapie bei ES. Für diese komplexen Ablationsprozeduren sind hochqualifizierte spezialisierte Zentren erforderlich.

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Conflict of interest. G. Al Mohani, C. Israel, and M. Casella state that there are no conflicts of interest. C. Carbucicchio is a consultant for BIOTRONIK.

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Correspondence to Ghaliah Al Mohani MD.

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Al Mohani, G., Israel, C., Casella, M. et al. Epicardial ablation as a bailout in electrical storm?. Herzschr Elektrophys 25, 93–101 (2014). https://doi.org/10.1007/s00399-014-0308-8

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  • DOI: https://doi.org/10.1007/s00399-014-0308-8

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