48. Should We Map and Ablate the Triggers, Substrates, Ventricular Tachycardia Circuit or All?

  1. Mohammad Shenasa MD2,
  2. Gerhard Hindricks MD3,
  3. Martin Borggrefe MD4,
  4. Günter Breithardt MD5 and
  5. Mark E. Josephson MD6
  1. Daniel Steven,
  2. Jakob Lüker,
  3. Arian Sultan,
  4. Imke Drewitz,
  5. Boris Hoffmann,
  6. Helge Servatius and
  7. Stephan Willems

Published Online: 18 DEC 2012

DOI: 10.1002/9781118481585.ch48

Cardiac Mapping, Fourth Edition

Cardiac Mapping, Fourth Edition

How to Cite

Steven, D., Lüker, J., Sultan, A., Drewitz, I., Hoffmann, B., Servatius, H. and Willems, S. (2013) Should We Map and Ablate the Triggers, Substrates, Ventricular Tachycardia Circuit or All?, in Cardiac Mapping, Fourth Edition (eds M. Shenasa, G. Hindricks, M. Borggrefe, G. Breithardt and M. E. Josephson), Wiley-Blackwell, Oxford, UK. doi: 10.1002/9781118481585.ch48

Editor Information

  1. 2

    Attending Physician, Department of Cardiovascular Services, O'Connor Hospital, Heart & Rhythm Medical Group, San Jose, California, USA

  2. 3

    Professor of Medicine (Cardiology), University Leipzig, Heart Center, Director, Department of Electrophysiology, Leipzig, Germany

  3. 4

    Professor of Medicine (Cardiology), Head, Department of Cardiology, Angiology and Pneumology, University Medical Center, Mannheim Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany

  4. 5

    Professor Emeritus of Medicine and Cardiology, Department of Cardiology and Angiology, Hospital of the University of Münster, Münster, Germany

  5. 6

    Chief, Cardiovascular Medicine Division, Director, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Herman C. Dana Professor of Medicine, Harvard Medical School, Boston, Massachusetts, USA

Author Information

  1. University Heart Center, Hamburg, Germany

Publication History

  1. Published Online: 18 DEC 2012
  2. Published Print: 10 JAN 2013

ISBN Information

Print ISBN: 9780470670460

Online ISBN: 9781118481585

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Keywords:

  • ventricular tachycardia;
  • substrate-based ablation;
  • reentry;
  • structural heart disease;
  • magnetic resonance imaging;
  • intracardiac echocardiography;
  • three-dimensional mapping;
  • critical isthmus;
  • premature ventricular contraction

Summary

Several ablation techniques for the treatment of ventricular tachycardia (VT) are well established: trigger ablation, substrate-based approaches and ablation of the VT circuit. Trigger ablation is mostly performed in idiopathic VT but does also play a role if triggers initiate VT in patients with structural or electrical heart disease. These ectopies may arise from the outflow tract area as they can be found in idiopathic VT but may also result from surviving strands of Purkinje fibers after myocardial infarction. The substrate-based approach has widely be refined not only by mapping of excitable areas within the scar zone most commonly displayed in three-dimensional (3D) mapping systems but also by newly evolving imaging strategies such as intracardiac echocardiography and magnetic resonance imaging that can be implemented in the 3D mapping system. Novel substrate-based mapping strategies target “local abnormal ventricular activity” with frequent epicardial ablation if possible. If VT is hemodynamically stable, mapping can be performed during entrainment and termination of VT can be considered as an endpoint for successful ablation. Mapping during VT should be considered as the first-line approach whenever feasible. Whatever mapping strategy is chosen, the procedure should be tailored to the individual patient. In most cases, a combination of different strategies is required to achieve favorable procedural outcomes.