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Winter 2013

Ablation for Ventricular Tachycardia May Be Underused

Dr. Edward Gerstenfekd

Dr. Edward Gerstenfeld

While ablation has shown remarkable success eliminating arrhythmias in the upper heart chambers, physicians to date use it only as a last resort for ventricular tachycardia (VT), says Edward Gerstenfeld, M.D., chief of the Cardiac Electrophysiology and Arrhythmia Service at UCSF.

But ablation may become the primary option in many more VT cases, given the risks and side effects associated with medications and new techniques that reduce ablation's risks and improve its efficacy, Gerstenfeld says.

"We can completely cure about half of those with VT, and another 30 percent will see many fewer episodes," says Gerstenfeld. "And if ablation can significantly reduce the number of shocks the defibrillator needs to administer — without the side effects of medication — that's a positive outcome. It means that rather than waiting until a patient is critically ill, ablation early on might save patients a lot of misery."

New Techniques Change the Picture

Advances, for example, allow electrophysiologists (EPs) to treat VT that originates on the outside of the heart. EPs use an epidural needle to enter the sac around the heart so they can map and ablate the source of the abnormal rhythm.

For challenging areas inside the heart, EPs can safely wire catheters through veins 85 percent to 90 percent of the time, though the risks become higher when the sites are too close to coronary arteries, says Gerstenfeld.

In addition, where percutaneous ablation is impossible — typically, where the VT origin is near a coronary artery or in the middle of the heart muscle — EPs and surgeons can work together to ablate in conjunction with an open-heart procedure. "At UCSF Medical Center, we are building a hybrid operating room, where we also have mapping systems in place, which should optimize this work," says Gerstenfeld.

Experience, Technology and Research

Right ventricle voltage map

Right ventricle epicardial
voltage map

Success rates depend on the experience of the EP as well as access to the latest equipment and resources. At UCSF Medical Center, vastly experienced EPs take advantage of the Biosense Webster CARTO 3 and EnSite NavX electro-anatomic mapping systems, intracardiac echocardiography, and Stereotaxis robotic navigation systems.

"We also have an inherited arrhythmia clinic, in cases where the cause may be genetic," says Gerstenfeld.

In addition, Gerstenfeld is leading a UCSF team enrolling patients in a study to examine the outcomes of early use of ablation versus medication — an important next step for understanding if early ablation is a valid consideration for VT treatment.

To contact Dr. Edward Gerstenfeld, call (415) 476-5706.

When to Refer

VT patients who are candidates for catheter ablation include the following:

  • Anyone with ischemic cardiomyopathy who has received one or more shocks from an implantable cardiac defibrillator (ICD)
  • Patients with frequent premature ventricular contractions, particularly those with reduced left ventricular (LV) function
  • Patients with nonischemic cardiomyopathy and a history of ICD shocks
  • Patients who may require additional medications to adjust their heart rhythm
  • Patients who want to consider alternatives to medications or surgery
  • Patients at risk for sudden death who require implantation of an ICD or biventricular ICD
  • Patients with inherited arrhythmia syndromes (long QT, Brugada, arrhythmogenic right ventricular cardiomyopathy)

 

Heart & Vascular Center News, Winter 2013 Index

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