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2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary

      Abstract

      Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

      Keywords

      Abbreviations:

      AAD (antiarrhythmic drug), AIV (anterior interventricular vein), AMC (aortomitral continuity), ARVC (arrhythmogenic right ventricular cardiomyopathy), ATP (antitachycardia pacing), AV (atrioventricular), BBRVT (bundle branch reentrant ventricular tachycardia), CHD (congenital heart disease), CMR (cardiac magnetic resonance imaging), COR (class of recommendation), CS (coronary sinus), DCM (dilated cardiomyopathy), EAM (electroanatomical mapping), ECG (electrocardiogram), GCV (great cardiac vein), HCM (hypertrophic cardiomyopathy), HS (hemodynamic support), ICD (implantable cardioverter defibrillator), ICE (intracardiac echocardiography), ICM (ischemic cardiomyopathy), IHD (ischemic heart disease), LBB (left bundle branch), LBBB (left bundle branch block), LMNA (lamin A/C), LOE (level of evidence), LSV (left sinus of Valsalva), LV (left ventricle), LVOT (left ventricular outflow tract), NCSV (noncoronary sinus of Valsalva), NICM (nonischemic cardiomyopathy), PES (programmed electrical stimulation), PVC (premature ventricular complex), RBB (right bundle branch), RBBB (right bundle branch block), RSV (right sinus of Valsalva), RV (right ventricle), RVOT (right ventricular outflow tract), RWI (relationship with industry and other entities), SHD (structural heart disease), SV (sinus of Valsalva), VA (ventricular arrhythmia), VF (ventricular fibrillation), VT (ventricular tachycardia)
      Document Reviewers: Samuel J. Asirvatham, MD, FHRS; Eduardo Back Sternick, MD, PhD; Janice Chyou, MD; Sabine Ernst, MD, PhD; Guilherme Fenelon, MD, PhD; Edward P. Gerstenfeld, MD, MS, FACC; Gerhard Hindricks, MD; Koichi Inoue, MD, PhD; Jeffrey J. Kim, MD; Kousik Krishnan, MD, FHRS, FACC; Karl-Heinz Kuck, MD, FHRS; Martin Ortiz Avalos, MD; Thomas Paul, MD, FACC, FHRS; Mauricio I. Scanavacca, MD, PhD; Roderick Tung, MD, FHRS; Jamie Voss, MBChB; Takumi Yamada, MD; Teiichi Yamane, MD, PhD, FHRS

      Section 1 Introduction

      1.1 Document Scope and Rationale

      The field of electrophysiology has undergone rapid progress in the last decade, with advances both in our understanding of the genesis of ventricular arrhythmias (VAs) and in the technology used to treat them. In 2009, a joint task force of the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS), in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA), produced an expert consensus document that outlined the state of the field and defined the indications, techniques, and outcome measures of VA ablation (
      • Aliot E.M.
      • Stevenson W.G.
      • Almendral-Garrote J.M.
      • et al.
      EHRA/HRS expert consensus on catheter ablation of ventricular arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA).
      ). In light of advances in the treatment of VAs in the interim, and the growth in the number of VA ablations performed in many countries and regions (
      • Hosseini S.M.
      • Rozen G.
      • Saleh A.
      • et al.
      Catheter ablation for cardiac arrhythmias: utilization and in-hospital complications, 2000 to 2013.
      ,
      • Raatikainen M.J.P.
      • Arnar D.O.
      • Merkely B.
      • Nielsen J.C.
      • Hindricks G.
      • Heidbuchel H.
      • Camm J.
      A decade of information on the use of cardiac implantable electronic devices and interventional electrophysiological procedures in the European Society of Cardiology Countries: 2017 report from the European Heart Rhythm Association.
      ), an updated document is needed. This effort represents a worldwide partnership between transnational cardiac electrophysiology societies, namely, HRS, EHRA, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS), and collaboration with ACC, AHA, the Japanese Heart Rhythm Society (JHRS), the Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardíacas [SOBRAC]), and the Pediatric and Congenital Electrophysiology Society (PACES). The consensus statement was also endorsed by the Canadian Heart Rhythm Society (CHRS).
      This clinical document is intended to supplement, not replace, the 2017 AHA/ACC/HRS Guideline for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (
      • Al-Khatib S.M.
      • Stevenson W.G.
      • Ackerman M.J.
      • et al.
      2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
      ) and the 2015 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (
      • Priori S.G.
      • Blomström-Lundqvist C.
      • Mazzanti A.
      • et al.
      Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC)
      2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC).
      ). The scope of the current document relates to ablation therapy for VAs, from premature ventricular complexes (PVCs) to monomorphic and polymorphic ventricular tachycardia (VT) and triggers of ventricular fibrillation (VF). Due to its narrower scope, the consensus statement delves into greater detail with regard to indications and technical aspects of VA ablation than the above-mentioned guidelines.
      Where possible, the recommendations in this document are evidence based. It is intended to set reasonable standards that can be applicable worldwide, while recognizing the different resources, technological availability, disease prevalence, and health care delivery logistics in various parts of the world. In addition, parts of this document, particularly Section 9, present a practical guide on how to accomplish the procedures described in a manner that reflects the current standard of care, while recognizing that some procedures are better performed, and some disease states better managed, in settings in which there is specific expertise.

      1.2 Methods

      The writing group was selected according to each society’s procedures, including content and methodology experts representing the following organizations: HRS, EHRA, APHRS, LAHRS, ACC, AHA, JHRS, PACES, and SOBRAC. Each partner society nominated a chair and co-chair, who did not have relevant relationships with industry and other entities (RWIs). In accordance with HRS policies, disclosure of any RWIs was required from the writing committee members (Appendix 1) and from all peer reviewers (Appendix 2). Of the 38 committee members, 17 (45%) had no relevant RWIs. Recommendations were drafted by the members who did not have relevant RWIs. Members of the writing group conducted comprehensive literature searches of electronic databases, including Medline (via PubMed), Embase, and the Cochrane Library. Evidence tables were constructed to summarize the retrieved studies, with nonrandomized observational designs representing the predominant form of evidence (Appendix 3). Case reports were not used to support recommendations. Supportive text was drafted in the “knowledge byte” format for each recommendation. The writing committee discussed all recommendations and the evidence that informed them before voting. Initial failure to reach consensus was resolved by subsequent discussions, revisions as needed, and re-voting. Although the consensus threshold was set at 67%, all recommendations were approved by at least 80% of the writing committee members. The mean consensus over all recommendations was 95%. A quorum of two-thirds of the writing committee was met for all votes (
      • Indik J.H.
      • Patton K.K.
      • Beardsall M.
      • et al.
      HRS clinical document development methodology manual and policies: executive summary.
      ).
      Each recommendation in this document was assigned a Class of Recommendation (COR) and a Level of Evidence (LOE) according to the system developed by ACC and AHA (Table 1) (
      • Halperin J.L.
      • Levine G.N.
      • Al-Khatib S.M.
      • et al.
      Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      ). The COR denotes the strength of the recommendation based on a careful assessment of the estimated benefits and risks; COR I indicates that the benefit of an intervention far exceeds its risk; COR IIa indicates that the benefit of the intervention moderately exceeds the risk; COR IIb indicates that the benefit may not exceed the risk; and COR III indicates that the benefit is equivalent to or is exceeded by the risk. The LOE reflects the quality of the evidence that supports the recommendation. LOE A is derived from high-quality randomized controlled trials; LOE B-R is derived from moderate-quality randomized controlled trials; LOE B-NR is derived from well-designed nonrandomized studies; LOE C-LD is derived from randomized or nonrandomized studies with limitations of design or execution; and LOE C-EO indicates that a recommendation was based on expert opinion (
      • Halperin J.L.
      • Levine G.N.
      • Al-Khatib S.M.
      • et al.
      Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      ).
      Table 1ACC/AHA Recommendation System: Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, and Diagnostic Testing in Patient Care∗
      Reproduced with permission of the American College of Cardiology (ACC) and the American Heart Association (AHA)
      • Halperin J.L.
      • Levine G.N.
      • Al-Khatib S.M.
      • et al.
      Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      .
      Unique to this consensus statement is the systematic review commissioned specifically for this document as part of HRS’s efforts to adopt the rigorous methodology required for guideline development. The systematic review was performed by an experienced evidence-based practice committee based at the University of Connecticut, which examined the question of VT ablation vs control in patients with VT and ischemic heart disease (IHD) (
      • Martinez B.K.
      • Baker W.L.
      • Konopka A.
      • et al.
      Systematic review and meta-analysis of catheter ablation of ventricular tachycardia in ischemic heart disease.
      ). The question, in PICOT format, was as follows: In adults with history of sustained VT and IHD, what is the effectiveness and what are the detriments of catheter ablation compared with other interventions? Components of the PICOT were as follows: P = adults with history of sustained VT and IHD; I = catheter ablation; C = control (no therapy or antiarrhythmic drug [AAD]); O = outcomes of interest, which included 1) appropriate implantable cardioverter defibrillator (ICD) therapies (ICD shock or antitachycardia pacing [ATP]), 2) appropriate ICD shocks, 3) VT storm (defined as three shocks within 24 hours), 4) recurrent VT/VF, 5) cardiac hospitalizations, and 6) all-cause mortality; and T = no time restrictions.
      An industry forum was conducted to achieve a structured dialogue to address technical questions and to gain a better understanding of future directions and challenges. Because of the potential for actual or perceived bias, HRS imposes strict parameters on information sharing to ensure that industry participates only in an advisory capacity and has no role in either the writing of the document or its review.
      The draft document underwent review by the HRS Scientific and Clinical Documents Committee and was approved by the writing committee. Recommendations were subject to a period of public comment, and the entire document underwent rigorous peer review by each of the participating societies and revision by the Chairs, before endorsement.

      Section 2 Background

      This section reviews the history of VT ablation, details the mechanisms of VT, and provides definitions of frequently used terms (Table 2), including anatomic definitions (Table 3), as well as illustrating some types of sustained VA (Figure 1).
      Table 2Definitions
      Clinical Characteristics
      Clinical ventricular tachycardia (VT): VT that has occurred spontaneously based on analysis of 12-lead electrocardiogram (ECG) QRS morphology.
      Hemodynamically unstable VT: causes hemodynamic compromise requiring prompt termination.
      Idiopathic VT: used to indicate VT that is known to occur in the absence of clinically apparent structural heart disease (SHD).
      Idioventricular rhythm: three or more consecutive beats at a rate of up to 100 per minute that originate from the ventricles independent of atrial or atrioventricular (AV) nodal conduction. Although various arbitrary rates have been used to distinguish it from VT, the mechanism of ventricular rhythm is more important than the rate. Idioventricular rhythm can be qualified as “accelerated” when the rate exceeds 40 bpm.
      Incessant VT: continuous sustained VT that recurs promptly despite repeated intervention for termination over several hours.
      Nonclinical VT: VT induced by programmed electrical stimulation (PES) that has not been documented previously.
      Nonsustained VT: terminates spontaneously within 30 seconds.
      PVC: premature ventricular complex; it is an early ventricular depolarization with or without mechanical contraction. We recommend avoiding the use of the terms “ventricular premature depolarization” and “premature ventricular contraction” to standardize the literature and acknowledge that early electrical activity does not necessarily lead to mechanical contraction.
      Presumptive clinical VT: similar to a spontaneous VT based on rate, limited ECG, or electrogram data available from ICD interrogation, but without the 12-lead ECG documentation of spontaneous VT.
      PVC burden: the amount of ventricular extrasystoles, preferably reported as the % of beats of ventricular origin of the total amount of beats over a 24-hour recording period.
      Repetitive monomorphic VT: continuously repeating episodes of self-terminating nonsustained VT.
      Sustained VT: continuous VT for 30 seconds, or which requires an intervention for termination (such as cardioversion).
      VT: a tachycardia (rate >100 bpm) with 3 or more consecutive beats that originates from the ventricles independent of atrial or AV nodal conduction.
      VT storm: three or more separate episodes of sustained VT within 24 hours, each requiring termination by an intervention.
      VT Morphologies
      Monomorphic VT: a similar QRS configuration from beat to beat (Figure 1A). Some variability in QRS morphology at initiation is not uncommon, followed by stabilization of the QRS morphology.
      Monomorphic VT with indeterminate QRS morphology: preferred over ventricular flutter; it is a term that has been applied to rapid VT that has a sinusoidal QRS configuration that prevents identification of the QRS morphology.
      Multiple monomorphic VTs: more than one morphologically distinct monomorphic VT, occurring as different episodes or induced at different times.
      Pleomorphic VT: has more than one morphologically distinct QRS complex occurring during the same episode of VT, but the QRS is not continuously changing (Figure 1B).
      Polymorphic VT: has a continuously changing QRS configuration from beat to beat, indicating a changing ventricular activation sequence (Figure 1C).
      Right bundle branch block (RBBB)- and left bundle branch block (LBBB)-like VT configurations: terms used to describe the dominant deflection in V1, with a dominant R wave described as “RBBB-like” and a dominant S wave with a negative final component in V1 described as “LBBB-like” configurations.
      Torsades de pointes: a form of polymorphic VT with continually varying QRS complexes that appear to spiral around the baseline of the ECG lead in a sinusoidal pattern. It is associated with QT prolongation.
      Unmappable VT: does not allow interrogation of multiple sites to define the activation sequence or perform entrainment mapping; this could be due to hemodynamic intolerance that necessitates immediate VT termination, spontaneous or pacing-induced transition to other morphologies of VT, or repeated termination during mapping.
      Ventricular fibrillation (VF): a chaotic rhythm defined on the surface ECG by undulations that are irregular in both timing and morphology, without discrete QRS complexes.
      PVC Morphologies
      Monomorphic PVC: PVCs felt reasonably to arise from the same focus. Slight changes in QRS morphology due to different exit sites from the same focus can be present.
      Multiple morphologies of PVC: PVCs originating from several different focal locations.
      Predominant PVC morphology: the one or more monomorphic PVC morphologies occurring most frequently and serving as the target for ablation.
      Mechanisms
      Focal VT: a point source of earliest ventricular activation with a spread of activation away in all directions from that site. The mechanism can be automaticity, triggered activity, or microreentry.
      Scar-related reentry: arrhythmias that have characteristics of reentry that originate from an area of myocardial scar identified from electrogram characteristics or myocardial imaging. Large reentry circuits that can be defined over several centimeters are commonly referred to as “macroreentry.”
      AV = atrioventricular; ECG = electrocardiogram; ICD = implantable cardioverter defibrillator; LBBB = left bundle branch block; PES = programmed electrical stimulation; PVC = premature ventricular complex; RBBB = right bundle branch block; SHD = structural heart disease; VT = ventricular tachycardia.
      Table 3Anatomical terminology
      TermDefinition
      RV inflowThe part of the right ventricle (RV) containing the tricuspid valve, chordae, and proximal RV.
      RV outflow tract (RVOT)The conus or infundibulum of the RV, derived from the bulbus cordis. It is bounded by the supraventricular crest and the pulmonic valve.
      Tricuspid annulusArea immediately adjacent to the tricuspid valve, including septal, free wall, and para-Hisian regions.
      Moderator bandA muscular band in the RV, typically located in the mid to apical RV, connecting the interventricular septum to the RV free wall, supporting the anterior papillary muscle. It typically contains a subdivision of the right bundle branch (RBB).
      RV papillary musclesThree muscles connecting the RV myocardium to the tricuspid valve via the tricuspid chordae tendineae, usually designated as septal, posterior, and anterior papillary muscles. The septal papillary muscle is closely associated with parts of the RBB.
      Supraventricular crestMuscular ridge in the RV between the tricuspid and pulmonic valves, representing the boundary between the conus arteriosus and the rest of the RV. The exact components and terminology are controversial; however, some characterize it as being composed of a parietal band that extends from the anterior RV free wall to meet the septal band, which extends from the septal papillary muscle to meet it.
      Pulmonary valvesThe pulmonic valve includes three cusps and associated sinus, variously named right, left, and anterior; or anterolateral right, anterolateral left, and posterior sinuses. The posterior-right anterolateral commissure adjoins the aorta (junction of the right and left aortic sinuses). Muscle is present in each of the sinuses, and VA can originate from muscle fibers located within or extending beyond the pulmonary valve apparatus.
      Sinuses of Valsalva (SV), aortic cusps, aortic commissuresThe right (R), left (L), and noncoronary aortic valve cusps are attached to the respective SV. The left sinus of Valsalva (LSV) is posterior and leftward on the aortic root. The noncoronary sinus of Valsalva (NCSV) is typically the most inferior and posterior SV, located posterior and rightward, superior to the His bundle, and anterior and superior to the paraseptal region of the atria near the superior AV junctions, typically adjacent to atrial myocardium. The right sinus of Valsalva (RSV) is the most anterior cusp and may be posterior to the RVOT infundibulum. VAs can also arise from muscle fibers at the commissures (connections) of the cusps, or from myocardium accessible to mapping and ablation from this location, especially from the RSV/LSV junction.
      LV outflow tract (LVOT)The aortic vestibule, composed of an infra-valvular part, bounded by the anterior mitral valve leaflet, but otherwise not clearly distinguishable from the rest of the LV; the aortic valve; and a supra-valvular part.
      LV ostiumThe opening at the base of the LV to which the mitral and aortic valves attach.
      Aortomitral continuity (AMC); aortomitral curtain, or mitral-aortic intervalvular fibrosaContinuation of the anteromedial aspect of the mitral annulus to the aortic valve; a curtain of fibrous tissue extending from the anterior mitral valve leaflet to the left and noncoronary aortic cusps. The AMC is connected by the left and right fibrous trigones to ventricular myocardium, the right fibrous trigone to the membranous ventricular septum.
      Mitral valve annulusArea immediately adjacent to the mitral valve. This can be approached endocardially, or epicardially, either through the coronary venous system or percutaneously.
      LV papillary musclesMuscles connecting the mitral valve chordae tendineae to the LV, typically with posteromedial and anterolateral papillary muscles. Papillary muscle anatomy is variable and can have single or multiple heads.
      LV false tendon (or LV moderator band)A fibrous or fibromuscular chord-like band that crosses the LV cavity, attaching to the septum, papillary muscles, trabeculations, or free wall of the LV. They may contain conduction tissue and may impede catheter manipulation in the LV.
      Posterior-superior processThe posterior-superior process of the left ventricle (LV) is the most inferior and posterior aspect of the basal LV, posterior to the plane of the tricuspid valve. VAs originating from the posterior-superior process of the LV can be accessed from the right atrium, the LV endocardium, and the coronary venous system.
      EndocardiumInner lining of the heart.
      Purkinje networkThe specialized conduction system of the ventricles, which includes the His bundle, RBB and left bundle branches (LBB), and the ramifications of these, found in the subendocardium. The Purkinje system can generate focal or reentrant VTs, typically manifesting Purkinje potentials preceding QRS onset.
      Interventricular septumMuscular wall between the LV and RV.
      Membranous ventricular septumThe ventricular septum beneath the RSV and NCSV, through which the penetrating His bundle reaches the ventricular myocardium.
      LV summitTriangular region of the most superior part of the LV epicardial surface bounded by the left circumflex coronary artery, the left anterior descending artery, and an approximate line from the first septal coronary artery laterally to the left AV groove. The great cardiac vein (GCV) bisects the triangle. An area superior to the GCV is considered to be inaccessible to catheter ablation due to proximity of the coronary arteries and overlying epicardial fat.
      Crux of the heart (crux cordis)Epicardial area formed by the junction of the AV groove and posterior interventricular groove, at the base of the heart, approximately at the junction of the middle cardiac vein and coronary sinus (CS) and near the origin of the posterior descending coronary artery.
      EpicardiumThe outer layer of the heart—the visceral layer of the serous pericardium.
      Epicardial fatAdipose tissue variably present over the epicardial surface around coronary arteries, LV apex, RV free wall, left atrial appendage, right atrial appendage, and AV and interventricular grooves.
      Pericardial space or cavityThe potential space between the parietal and visceral layers of serous pericardium, which normally contains a small amount of serous fluid. This space can be accessed for epicardial procedures.
      Parietal pericardiumThe layer of the serous pericardium that is attached to the inner surface of the fibrous pericardium and is normally apposed to the visceral pericardium, separated by a thin layer of pericardial fluid.
      Fibrous pericardiumThick membrane that forms the outer layer of the pericardium.
      Subxiphoid areaArea inferior to the xiphoid process; typical site for percutaneous epicardial access.
      Phrenic nerveThe right phrenic nerve lays along the right atrium and does not usually pass over ventricular tissue. The course of the left phrenic nerve on the fibrous pericardium can be quite variable and may run along the lateral margin of the LV near the left obtuse marginal artery and vein; inferior, at the base of the heart; or anterior over the sternocostal surface over the L main stem coronary artery or left anterior descending artery.
      Coronary sinus (CS) and branchesThe CS and its branches comprise the coronary venous system with the ostium of the CS opening into the right atrium. Tributaries of the CS, which runs along the left AV groove, may be used for mapping. These include the anterior interventricular vein (AIV), which arises at the apex and runs along the anterior interventricular septum, connecting to the GCV that continues in the AV groove to the CS; the communicating vein located between aortic and pulmonary annulus; various posterior and lateral marginal branches or perforator veins; and the middle cardiac vein that typically runs along the posterior interventricular septum from the apex to join the CS or empty separately into the right atrium. The junction of the GCV and the CS is at the vein or ligament of Marshall (or persistent left superior vena cava, when present), and the valve of Vieussens (where present).
      Anatomical terminology
      • Yamada T.
      • Kay G.N.
      Anatomical consideration in catheter ablation of idiopathic ventricular arrhythmias.
      ,
      • Della Bella P.
      • Maccabelli G.
      • Carbucicchio C.
      Anatomical assessment for catheter ablation of ventricular tachycardia.
      ,
      • Enriquez A.
      • Malavassi F.
      • Saenz L.C.
      • Supple G.
      • Santangeli P.
      • Marchlinski F.E.
      • Garcia F.C.
      How to map and ablate left ventricular summit arrhythmias.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • Ho S.Y.
      Anatomic insights for catheter ablation of ventricular tachycardia.
      ,
      • Ho S.Y.
      • Nihoyannopoulos P.
      Anatomy, echocardiography, and normal right ventricular dimensions.
      ,
      • Sánchez-Quintana D.
      • Ho S.Y.
      • Climent V.
      • Murillo M.
      • Cabrera J.A.
      Anatomic evaluation of the left phrenic nerve relevant to epicardial and endocardial catheter ablation: implications for phrenic nerve injury.
      ,
      • Yamada T.
      • Litovsky S.H.
      • Kay G.N.
      The left ventricular ostium: an anatomic concept relevant to idiopathic ventricular arrhythmias.
      ,
      • McAlpine W.A.
      Heart and Coronary Arteries: An Anatomical Atlas for Clinical Diagnosis, Radiological Investigation, and Surgical Treatment.
      . See also Figures 3, 4, 7, and 8. AIV = anterior interventricular vein; AMC = aortomitral continuity; AV = atrioventricular; CS = coronary sinus; GCV = great cardiac vein; LBB = left bundle branch; LSV = left sinus of Valsalva; LV = left ventricle; LVOT = left ventricular outflow tract; NCSV = noncoronary sinus of Valsalva; RBB = right bundle branch; RSV = right sinus of Valsalva; RV = right ventricle; RVOT = right ventricular outflow tract; SV = sinus of Valsalva; VA = ventricular arrhythmia; VT = ventricular tachycardia.
      Figure thumbnail gr1
      Figure 1Monomorphic (A), pleomorphic (B), and polymorphic (C) VT. Reproduced with permission of the Heart Rhythm Society from Aliot et al. EHRA/HRS expert consensus on catheter ablation of ventricular arrhythmias. Heart Rhythm 2009;6:886–933. VT = ventricular tachycardia.

      Section 3 Clinical Evaluation

      This section discusses clinical presentations of patients with VAs and their workup as it pertains to documentation of arrhythmias and appropriate testing to assess for the presence of SHD.

      3.1 Clinical Presentation

      Tabled 1Recommendation for clinical evaluation of patients with VAs
      CORLOERecommendation
      IC-EO
      • 1.
        A careful clinical evaluation including history, physical examination, review of available cardiac rhythm data, prior imaging, and relevant laboratory workup should be performed in patients presenting with VAs.

      3.2 Diagnostic Evaluation

      3.2.1 Resting 12-Lead Electrocardiogram

      Tabled 1Recommendations for resting 12-lead ECG
      CORLOERecommendationsReferences
      IB-NR
      • 1.
        In patients with wide complex tachycardia, a 12-lead ECG during tachycardia should be obtained whenever possible.
      • Brugada P.
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      • Smeets J.
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      A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex.
      ,
      • Wellens H.J.
      • Bar F.W.
      • Lie K.I.
      The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.
      ,
      • Vereckei A.
      • Duray G.
      • Szenasi G.
      • Altemose G.T.
      • Miller J.M.
      New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia.
      ,
      • Ohe T.
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      • et al.
      Idiopathic sustained left ventricular tachycardia: clinical and electrophysiologic characteristics.
      ,
      • Dixit S.
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      • Callans D.J.
      • Marchlinski F.E.
      Electrocardiographic patterns of superior right ventricular outflow tract tachycardias: distinguishing septal and free-wall sites of origin.
      ,
      • Callans D.J.
      • Menz V.
      • Schwartzman D.
      • Gottlieb C.D.
      • Marchlinski F.E.
      Repetitive monomorphic tachycardia from the left ventricular outflow tract: electrocardiographic patterns consistent with a left ventricular site of origin.
      ,
      • Kanagaratnam L.
      • Tomassoni G.
      • Schweikert R.
      • et al.
      Ventricular tachycardias arising from the aortic sinus of Valsalva: an under-recognized variant of left outflow tract ventricular tachycardia.
      ,
      • Crawford T.
      • Mueller G.
      • Good E.
      • et al.
      Ventricular arrhythmias originating from papillary muscles in the right ventricle.
      ,
      • Yamada T.
      • McElderry H.T.
      • Okada T.
      • et al.
      Idiopathic focal ventricular arrhythmias originating from the anterior papillary muscle in the left ventricle.
      ,
      • Li S.
      • Wang Z.
      • Shan Z.
      • et al.
      Surface electrocardiography characteristics and radiofrequency catheter ablation of idiopathic ventricular arrhythmias originating from the left infero-septal papillary muscles: differences from those originating from the left posterior fascicle.
      ,
      • Berruezo A.
      • Mont L.
      • Nava S.
      • Chueca E.
      • Bartholomay E.
      • Brugada J.
      Electrocardiographic recognition of the epicardial origin of ventricular tachycardias.
      ,
      • Daniels D.V.
      • Lu Y.Y.
      • Morton J.B.
      • et al.
      Idiopathic epicardial left ventricular tachycardia originating remote from the sinus of Valsalva: electrophysiological characteristics, catheter ablation, and identification from the 12-lead electrocardiogram.
      ,
      • Bazan V.
      • Gerstenfeld E.P.
      • Garcia F.C.
      • et al.
      Site-specific twelve-lead ECG features to identify an epicardial origin for left ventricular tachycardia in the absence of myocardial infarction.
      ,
      • Valles E.
      • Bazan V.
      • Marchlinski F.E.
      ECG Criteria to identify epicardial ventricular tachycardia in nonischemic cardiomyopathy.
      ,
      • Bazan V.
      • Bala R.
      • Garcia F.C.
      • et al.
      Twelve-lead ECG features to identify ventricular tachycardia arising from the epicardial right ventricle.
      IB-NR
      • 2.
        In patients with suspected or documented VA, a 12-lead ECG should be obtained in sinus rhythm to look for evidence of underlying heart disease.
      • Perez-Rodon J.
      • Martinez-Alday J.
      • Baron-Esquivias G.
      • et al.
      Prognostic value of the electrocardiogram in patients with syncope: data from the group for syncope study in the emergency room (GESINUR).

      3.2.2 Assessment of Structural Heart Disease and Myocardial Ischemia

      Tabled 1Recommendations for assessment of SHD and myocardial ischemia
      CORLOERecommendationsReferences
      IB-NR
      • 1.
        In patients with known or suspected VA, echocardiography is recommended for evaluation of cardiac structure and function.
      • Solomon S.D.
      • Zelenkofske S.
      • McMurray J.J.
      • et al.
      Sudden death in patients with myocardial infarction and left ventricular dysfunction, heart failure, or both.
      ,
      • Gula L.J.
      • Klein G.J.
      • Hellkamp A.S.
      • et al.
      Ejection fraction assessment and survival: an analysis of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).
      IIaB-NR
      • 2.
        In patients presenting with VA who are suspected of having SHD, even after normal echocardiographic evaluation, advanced cardiac imaging can be useful to detect and characterize underlying SHD.
      • Yoon Y.
      • Ktagawa K.
      • Kato S.
      • et al.
      Prognostic value of unrecognised myocardial infarction detected by late gadolinium-enhanced MRI in diabetic patients with normal global and regional left ventricular systolic function.
      ,
      • Olivotto I.
      • Maron M.
      • Autore C.
      • et al.
      Assessment and significance of left ventricular mass by cardiovascular magnetic resonance in hypertrophic cardiomyopathy.
      ,
      • Desjardins B.
      • Yokokawa M.
      • Good E.
      • et al.
      Characteristics of intramural scar in patients with nonischemic cardiomyopathy and relation to intramural ventricular arrhythmias.
      ,
      • Dweck M.
      • Abgral R.
      • Trivieri M.
      • et al.
      Hybrid magnetic resonance imaging and positron emission tomography with fluorodeoxyglucose to diagnose active cardiac sarcoidosis.
      ,
      • Piers S.R.
      • Tao Q.
      • van Huls van Taxis C.F.
      • Schalij M.J.
      • van der Geest R.J.
      • Zeppenfeld K.
      Contrast-enhanced MRI-derived scar patterns and associated ventricular tachycardias in nonischemic cardiomyopathy: implications for the ablation strategy.
      IIaC-EO
      • 3.
        In patients with VA in whom myocardial ischemia is suspected, stress testing and/or coronary angiography and subsequent revascularization can be beneficial before catheter ablation to avoid significant ischemia during induced VT.
      III: No BenefitB-NR
      • 4.
        In patients presenting with monomorphic VT, revascularization alone is not effective to prevent VT recurrence.
      • Brugada J.
      • Aguinaga L.
      • Mont L.
      • Betriu A.
      • Mulet J.
      • Sanz G.
      Coronary artery revascularization in patients with sustained ventricular arrhythmias in the chronic phase of a myocardial infarction: effects on the electrophysiologic substrate and outcome.
      ,
      • Nageh M.
      • Kim J.
      • Chen L.
      • Yao J.F.
      Implantable defibrillators for secondary prevention of sudden cardiac death in cardiac surgery patients with perioperative ventricular arrhythmias.
      ,
      • Elsokkari I.
      • Parkash R.
      • Gray C.
      • et al.
      Effect of coronary revascularization on long-term clinical outcomes in patients with ischemic cardiomyopathy and recurrent ventricular arrhythmia.

      3.2.3 Risk Stratification in the Setting of Frequent Premature Ventricular Complexes

      Tabled 1Recommendations for cardiac magnetic resonance imaging (CMR) in patients with frequent PVCs and for PES in patients with SHD and frequent PVCs
      CORLOERecommendationsReferences
      IIaB-NR
      • 1.
        CMR can be useful for risk stratification for sudden cardiac death in patients with frequent PVCs.
      • Aquaro G.D.
      • Pingitore A.
      • Strata E.
      • Di Bella G.
      • Molinaro S.
      • Lombardi M.
      Cardiac magnetic resonance predicts outcome in patients with premature ventricular complexes of left bundle branch block morphology.
      ,
      • Yokokawa M.
      • Siontis K.C.
      • Kim H.M.
      • et al.
      Value of cardiac magnetic resonance imaging and programmed ventricular stimulation in patients with frequent premature ventricular complexes undergoing radiofrequency ablation.
      IIaC-LD
      • 2.
        PES can be useful for risk stratification for sudden cardiac death in patients with SHD undergoing ablation of frequent PVCs.
      • Yokokawa M.
      • Siontis K.C.
      • Kim H.M.
      • et al.
      Value of cardiac magnetic resonance imaging and programmed ventricular stimulation in patients with frequent premature ventricular complexes undergoing radiofrequency ablation.

      3.2.4 Longitudinal Follow-up in the Setting of Frequent Premature Ventricular Complexes

      Tabled 1Recommendation for longitudinal follow-up of patients with frequent PVCs
      CORLOERecommendationReference
      IIaB-NR
      • 1.
        Periodic monitoring of PVC burden and LV function and dimensions can be useful in patients with frequent, asymptomatic PVCs and normal LV function and dimensions.
      • Niwano S.Y.
      • Wakisaka H.
      • Niwano H.
      • et al.
      Prognostic significance of frequent premature ventricular contractions originating from the ventricular outflow tract in patients with normal left ventricular function.

      Section 4 Indications for Catheter Ablation

      Following are the consensus recommendations for catheter ablation of VAs organized by underlying diagnosis and substrate. These recommendations are each assigned a COR and an LOE according to the current recommendation classification system (
      • Halperin J.L.
      • Levine G.N.
      • Al-Khatib S.M.
      • et al.
      Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines.
      ). In drafting each of these recommendations, the writing committee took into account the published literature in the specific area, including the methodological quality and size of each study, as well as the collective clinical experience of the writing group when published data were not available. Implicit in each recommendation are several points: 1) the procedure is being performed by an electrophysiologist with appropriate training and experience in the procedure and in a facility with appropriate resources; 2) patient and procedural complexity vary widely, and some patients or situations merit a more experienced operator or a center with more capabilities than others, even within the same recommendation (eg, when an epicardial procedure is indicated and the operator or institution has limited experience with this procedure, it might be preferable to refer the patient to an operator or institution with adequate experience in performing epicardial procedures); 3) the patient is an appropriate candidate for the procedure, as outlined in Section 5, recognizing that the level of patient suitability for a procedure will vary widely with the clinical scenario; and 4) the patient’s (or designee’s) informed consent, values, and overall clinical trajectory are fundamental to a decision to proceed (or not) with any procedure. Therefore, in some clinical scenarios, initiation or continuation of medical therapy instead of an ablation procedure may be the most appropriate option, even when a class 1 recommendation for ablation is present. There may also be scenarios not explicitly covered in this document, and on which little or no published literature is available, in which the physician and patient must rely solely on their own judgment.
      Figure 2 provides an overview of care for the patient with congenital heart disease (CHD) and VA.
      Figure thumbnail gr2
      Figure 2Congenital heart disease and sustained VT. For further discussion of ICD candidacy, please see PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease
      (
      • Khairy P.
      • Van Hare G.F.
      • Balaji S.
      • et al.
      PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD).
      )
      and 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities
      (
      • Tracy C.M.
      • Epstein A.E.
      • Darbar D.
      • et al.
      2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
      )
      . ACA = aborted cardiac arrest; CHD = congenital heart disease; DORV = double outlet right ventricle; ICD = implantable cardioverter defibrillator; TOF = tetralogy of Fallot; VT = ventricular tachycardia.

      4.1 Idiopathic Outflow Tract Ventricular Arrhythmia

      Tabled 1Recommendations for catheter ablation of idiopathic outflow tract VA
      CORLOERecommendationsReferences
      IB-R
      • 1.
        In patients with frequent and symptomatic PVCs originating from the RVOT in an otherwise normal heart, catheter ablation is recommended in preference to metoprolol or propafenone.
      • Ling Z.
      • Liu Z.
      • Su L.
      • et al.
      Radiofrequency ablation versus antiarrhythmic medication for treatment of ventricular premature beats from the right ventricular outflow tract: prospective randomized study.
      IB-NR
      • 2.
        In patients with symptomatic VAs from the RVOT in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation is useful.
      • Zhang F.
      • Yang B.
      • Chen H.
      • Ju W.
      • Kojodjojo P.
      • Cao K.
      • Chen M.
      Magnetic versus manual catheter navigation for mapping and ablation of right ventricular outflow tract ventricular arrhythmias: a randomized controlled study.
      ,
      • Krittayaphong R.
      • Sriratanasathavorn C.
      • Dumavibhat C.
      • et al.
      Electrocardiographic predictors of long term outcomes after radiofrequency ablation in patients with right-ventricular outflow tract tachycardia.
      ,
      • Vestal M.
      • Wen M.S.
      • Yeh S.J.
      • Wang C.C.
      • Lin F.C.
      • Wu D.
      Electrocardiographic predictors of failure and recurrence in patients with idiopathic right ventricular outflow tract tachycardia and ectopy who underwent radiofrequency catheter ablation.
      ,
      • Miyazawa K.
      • Ueda M.
      • Kondo Y.
      • Hayashi T.
      • Nakano M.
      • Ishimura M.
      • Nakano M.
      • Kobayashi Y.
      Rapid mapping and differentiation in ventricular outflow tract arrhythmia using non-contact mapping.
      ,
      • Akdeniz C.
      • Gul E.E.
      • Celik N.
      • Karacan M.
      • Tuzcu V.
      Catheter ablation of idiopathic right ventricular arrhythmias in children with limited fluoroscopy.
      ,
      • Morady F.
      • Kadish A.H.
      • DiCarlo L.
      • Kou W.H.
      • Winston S.
      • deBuitlier M.
      • Calkins H.
      • Rosenheck S.
      • Sousa J.
      Long-term results of catheter ablation of idiopathic right ventricular tachycardia.
      ,
      • Liao Z.
      • Zhan X.
      • Wu S.
      • et al.
      Idiopathic ventricular arrhythmias originating from the pulmonary sinus cusp: prevalence, electrocardiographic/electrophysiological characteristics, and catheter ablation.
      ,
      • Bogun F.
      • Crawford T.
      • Reich S.
      • Koelling T.M.
      • Armstrong W.
      • Good E.
      • Jongnarangsin K.
      • Marine J.E.
      • Chugh A.
      • Pelosi F.
      • Oral H.
      • Morady F.
      Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: comparison with a control group without intervention.
      ,
      • Chen H.
      • Shehata M.
      • Swerdlow C.
      • et al.
      Intramural outflow tract ventricular tachycardia: anatomy, mapping, and ablation.
      ,
      • Teh A.W.
      • Reddy V.Y.
      • Koruth J.S.
      • et al.
      Bipolar radiofrequency catheter ablation for refractory ventricular outflow tract arrhythmias.
      ,
      • Lamba J.
      • Redfearn D.P.
      • Michael K.A.
      • Simpson C.S.
      • Abdollah H.
      • Baranchuk A.
      Radiofrequency catheter ablation for the treatment of idiopathic premature ventricular contractions originating from the right ventricular outflow tract: a systematic review and meta-analysis.
      IB-NR
      • 3.
        In patients with symptomatic idiopathic sustained monomorphic VT, catheter ablation is useful.
      • Calkins H.
      • Kalbfleisch J.
      • El-Atassi R.
      • Langberg J.
      • Morady F.
      Relation between efficacy of radiofrequency catheter ablation and site of origin of idiopathic ventricular tachycardia.
      ,
      • Rodriguez L.M.
      • Smeets J.L.
      • Timmermans C.
      • Wellens H.J.
      Predictors for successful ablation of right- and left-sided idiopathic ventricular tachycardia.
      ,
      • Coggins D.L.
      • Lee R.J.
      • Sweeney J.
      • et al.
      Radiofrequency catheter ablation as a cure for idiopathic tachycardia of both left and right ventricular origin.
      ,
      • Wen M.S.
      • Yeh S.J.
      • Wang C.C.
      • Lin F.C.
      • Chen I.C.
      • Wu D.
      Radiofrequency ablation therapy in idiopathic left ventricular tachycardia with no obvious structural heart disease.
      ,
      • Movsowitz C.
      • Schwartzman D.
      • Callans D.J.
      • et al.
      Idiopathic right ventricular outflow tract tachycardia: narrowing the anatomic location for successful ablation.
      IIaB-NR
      • 4.
        In patients with symptomatic VAs from the endocardial LVOT, including the SV, in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation can be useful.
      • Frey B.
      • Kreiner G.
      • Fritsch S.
      • Veit F.
      • Gossinger H.D.
      Successful treatment of idiopathic left ventricular outflow tract tachycardia by catheter ablation or minimally invasive surgical cryoablation.
      ,
      • Krebs M.E.
      • Krause P.C.
      • Engelstein E.D.
      • Zipes D.P.
      • Miles W.M.
      Ventricular tachycardias mimicking those arising from the right ventricular outflow tract.
      ,
      • Kumagai K.
      • Fukuda K.
      • Wakayama Y.
      • et al.
      Electrocardiographic characteristics of the variants of idiopathic left ventricular outflow tract ventricular tachyarrhythmias.
      ,
      • Latchamsetty R.
      • Yokokawa M.
      • Morady F.
      • et al.
      Multicenter outcomes for catheter ablation of idiopathic premature ventricular complexes.
      ,
      • Kamakura S.
      • Shimizu W.
      • Matsuo K.
      • et al.
      Localization of optimal ablation site of idiopathic ventricular tachycardia from right and left ventricular outflow tract by body surface ECG.
      ,
      • Yamada T.
      • Yoshida N.
      • Murakami Y.
      • et al.
      Electrocardiographic characteristics of ventricular arrhythmias originating from the junction of the left and right coronary sinuses of Valsalva in the aorta: the activation pattern as a rationale for the electrocardiographic characteristics.
      ,
      • Tada H.
      • Naito S.
      • Ito S.
      • et al.
      Significance of two potentials for predicting successful catheter ablation from the left sinus of Valsalva for left ventricular epicardial tachycardia.
      ,
      • Ouyang F.
      • Fotuhi P.
      • Ho S.Y.
      • et al.
      Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: electrocardiographic characterization for guiding catheter ablation.
      ,
      • Callans D.J.
      • Menz V.
      • Schwartzman D.
      • Gottlieb C.D.
      • Marchlinski F.E.
      Repetitive monomorphic tachycardia from the left ventricular outflow tract: electrocardiographic patterns consistent with a left ventricular site of origin.
      ,
      • Bala R.
      • Garcia F.C.
      • Hutchinson M.D.
      • et al.
      Electrocardiographic and electrophysiologic features of ventricular arrhythmias originating from the right/left coronary cusp commissure.
      IIaB-NR
      • 5.
        In patients with symptomatic VAs from the epicardial outflow tract or LV summit in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation can be useful.
      • Tada H.
      • Nogami A.
      • Naito S.
      • et al.
      Left ventricular epicardial outflow tract tachycardia: a new distinct subgroup of outflow tract tachycardia.
      ,
      • Baman T.S.
      • Ilg K.J.
      • Gupta S.K.
      • et al.
      Mapping and ablation of epicardial idiopathic ventricular arrhythmias from within the coronary venous system.
      ,
      • Carrigan T.
      • Patel S.
      • Yokokawa M.
      • Schmidlin E.
      • Swanson S.
      • Morady F.
      • Bogun F.
      Anatomic relationships between the coronary venous system, surrounding structures, and the site of origin of epicardial ventricular arrhythmias.
      ,
      • Santangeli P.
      • Marchlinski F.E.
      • Zado E.S.
      • et al.
      Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit: outcomes and electrocardiogram correlates of success.
      ,
      • Nagashima K.
      • Choi E.K.
      • Lin K.Y.
      • et al.
      Ventricular arrhythmias near the distal great cardiac vein: challenging arrhythmia for ablation.

      4.2 Idiopathic Nonoutflow Tract Ventricular Arrhythmia

      Tabled 1Recommendations for catheter ablation of nonoutflow tract VAs in the absence of SHD
      CORLOERecommendationsReferences
      IB-NR
      • 1.
        In patients with symptomatic VAs from the RV at sites other than the outflow tracts (tricuspid annulus, moderator band, parietal band, or papillary muscles) in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation is useful.
      • Van Herendael H.
      • Garcia F.
      • Lin D.
      • et al.
      Idiopathic right ventricular arrhythmias not arising from the outflow tract: prevalence, electrocardiographic characteristics, and outcome of catheter ablation.
      ,
      • Sadek M.M.
      • Benhayon D.
      • Sureddi R.
      • et al.
      Idiopathic ventricular arrhythmias originating from the moderator band: electrocardiographic characteristics and treatment by catheter ablation.
      ,
      • Crawford T.
      • Mueller G.
      • Good E.
      • et al.
      Ventricular arrhythmias originating from papillary muscles in the right ventricle.
      ,
      • Tada H.
      • Tadokoro K.
      • Miyaji K.
      • et al.
      Idiopathic ventricular arrhythmias arising from the pulmonary artery: prevalence, characteristics, and topography of the arrhythmia origin.
      ,
      • Tada H.
      • Tadokoro K.
      • Ito S.
      • et al.
      Idiopathic ventricular arrhythmias originating from the tricuspid annulus: prevalence, electrocardiographic characteristics, and results of radiofrequency catheter ablation.
      ,
      • Santoro F.
      • DiBiase L.
      • Hranitzky P.
      • et al.
      Ventricular tachycardia originating from the septal papillary muscle of the right ventricle: electrocardiographic and electrophysiological characteristics.
      ,
      • Sasaki K.
      • Sasaki S.
      • Kimura M.
      • et al.
      Catheter ablation of ventricular arrhythmias arising from the basal septum of the right ventricle: characteristics and significance of junctional rhythm appearing during ablation.
      ,
      • Yue-Chun L.
      • Wen-Wu Z.
      • Na-Dan Z.
      • et al.
      Idiopathic premature ventricular contractions and ventricular tachycardias originating from the vicinity of tricuspid annulus: results of radiofrequency catheter ablation in thirty-five patients.
      ,
      • Yamada T.
      • Yoshida N.
      • Itoh T.
      • Litovsky S.H.
      • Doppalapudi H.
      • McElderry H.T.
      • Kay G.N.
      Idiopathic ventricular arrhythmias originating from the parietal band: electrocardiographic and electrophysiological characteristics and outcome of catheter ablation.
      ,
      • Ceresnak S.R.
      • Pass R.H.
      • Krumerman A.K.
      • Kim S.G.
      • Nappo L.
      • Fisher J.D.
      Characteristics of ventricular tachycardia arising from the inflow region of the right ventricle.
      ,
      • Yamada T.
      • Yoshida N.
      • Litovsky S.H.
      • Itoh T.
      • Doppalapudi H.
      • Kay G.N.
      Idiopathic ventricular arrhythmias originating from the infundibular muscles: prevalence, electrocardiographic and electrophysiological characteristics, and outcome of catheter ablation.
      ,
      • Li T.
      • Zhan X.Z.
      • Xue Y.M.
      • et al.
      Combined approach improves the outcomes of catheter ablation of idiopathic ventricular arrhythmias originating from the vicinity of tricuspid annulus.
      ,
      • Lian-Pin W.
      • Yue-Chun L.
      • Jing-Lin Z.
      • et al.
      Catheter ablation of idiopathic premature ventricular contractions and ventricular tachycardias originating from right ventricular septum.
      ,
      • Enriquez A.
      • Pathak R.K.
      • Santangeli P.
      • et al.
      Inferior lead discordance in ventricular arrhythmias: a specific marker for certain arrhythmia locations.
      IB-NR
      • 2.
        In patients with symptomatic VAs from the LV at sites other than the outflow tracts (mitral annulus, papillary muscles, or AMC) in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation is useful.
      • Doppalapudi H.
      • Yamada T.
      • McElderry H.T.
      • Plumb V.J.
      • Epstein A.E.
      • Kay G.N.
      Ventricular tachycardia originating from the posterior papillary muscle in the left ventricle: a distinct clinical syndrome.
      ,
      • Yamada T.
      • McElderry H.T.
      • Okada T.
      • et al.
      Idiopathic focal ventricular arrhythmias originating from the anterior papillary muscle in the left ventricle.
      ,
      • Yamada T.
      • Doppalapudi H.
      • McElderry H.T.
      • et al.
      Idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle: prevalence, electrocardiographic and electrophysiological characteristics, and results of the radiofrequency catheter ablation.
      ,
      • Yamada T.
      • Doppalapudi H.
      • McElderry H.T.
      • et al.
      Electrocardiographic and electrophysiological characteristics in idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle: relevance for catheter ablation.
      ,
      • Bassil G.
      • Liu C.F.
      • Markowitz S.M.
      • et al.
      Comparison of robotic magnetic navigation-guided and manual catheter ablation of ventricular arrhythmias arising from the papillary muscles.
      ,
      • Ban J.E.
      • Lee H.S.
      • Lee D.I.
      • et al.
      Electrophysiological characteristics related to outcome after catheter ablation of idiopathic ventricular arrhythmia originating from the papillary muscle in the left ventricle.
      ,
      • Yokokawa M.
      • Good E.
      • Desjardins B.
      • et al.
      Predictors of successful catheter ablation of ventricular arrhythmias arising from the papillary muscles.
      ,
      • Rivera S.
      • Ricapito Mde L.
      • Tomas L.
      • et al.
      Results of cryoenergy and radiofrequency-based catheter ablation for treating ventricular arrhythmias arising from the papillary muscles of the left ventricle, guided by intracardiac echocardiography and image integration.
      ,
      • Al’Aref S.J.
      • Ip J.E.
      • Markowitz S.M.
      • et al.
      Differentiation of papillary muscle from fascicular and mitral annular ventricular arrhythmias in patients with and without structural heart disease.
      ,
      • Wasmer K.
      • Köbe J.
      • Dechering D.G.
      • et al.
      Ventricular arrhythmias from the mitral annulus: patient characteristics, electrophysiological findings, ablation, and prognosis.
      ,
      • Kumagai K.
      • Yamauchi Y.
      • Takahashi A.
      • et al.
      Idiopathic left ventricular tachycardia originating from the mitral annulus.
      ,
      • Tada H.
      • Ito S.
      • Naito S.
      • et al.
      Idiopathic ventricular arrhythmia arising from the mitral annulus: a distinct subgroup of idiopathic ventricular arrhythmias.
      ,
      • Yue-Chun L.
      • Cheng Z.
      • Jun H.
      • Jun-Hua C.
      • Jing-Lin Z.
      • Jia-Feng L.
      Catheter ablation of idiopathic premature ventricular contractions and ventricular tachycardias originating from the vicinity of endocardial and epicardial mitral annulus.
      ,
      • Yamada T.
      • Doppalapudi H.
      • McElderry H.T.
      • Kay G.N.
      Idiopathic mitral annular PVCs with multiple breakouts and preferential conduction unmasked by radiofrequency catheter ablation.
      ,
      • Yamada T.
      • Litovsky S.H.
      • Kay G.N.
      The left ventricular ostium: an anatomic concept relevant to idiopathic ventricular arrhythmias.
      ,
      • Chen J.
      • Hoff P.I.
      • Rossvoll O.
      • et al.
      Ventricular arrhythmias originating from the aortomitral continuity: an uncommon variant of left ventricular outflow tract tachycardia.
      ,
      • Hai J.J.
      • Chahal A.A.
      • Friedman P.A.
      • et al.
      Electrophysiologic characteristics of ventricular arrhythmias arising from the aortic mitral continuity-potential role of the conduction system.
      IIaB-NR
      • 3.
        In patients with symptomatic VAs from the epicardial coronary venous system in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation can be useful.
      • Yamada T.
      • McElderry H.T.
      • Doppalapudi H.
      • et al.
      Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation.
      ,
      • Baman T.S.
      • Ilg K.J.
      • Gupta S.K.
      • et al.
      Mapping and ablation of epicardial idiopathic ventricular arrhythmias from within the coronary venous system.
      ,
      • Mountantonakis S.E.
      • Frankel D.S.
      • Tschabrunn C.M.
      • et al.
      Ventricular arrhythmias from the coronary venous system: prevalence, mapping, and ablation.
      ,
      • Meininger G.R.
      • Berger R.D.
      Idiopathic ventricular tachycardia originating in the great cardiac vein.
      ,
      • Yamada T.
      • Doppalapudi H.
      • Litovsky S.H.
      • McElderry H.T.
      • Kay G.N.
      Challenging radiofrequency catheter ablation of idiopathic ventricular arrhythmias originating from the left ventricular summit near the left main coronary artery.
      ,
      • Yokokawa M.
      • Latchamsetty R.
      • Good E.
      • et al.
      Ablation of epicardial ventricular arrhythmias from nonepicardial sites.
      ,
      • Jauregui Abularach M.E.
      • Campos B.
      • Park K.M.
      • et al.
      Ablation of ventricular arrhythmias arising near the anterior epicardial veins from the left sinus of Valsalva region: ECG features, anatomic distance, and outcome.
      ,
      • Yokokawa M.
      • Good E.
      • Chugh A.
      • et al.
      Intramural idiopathic ventricular arrhythmias originating in the intraventricular septum: mapping and ablation.
      ,
      • Doppalapudi H.
      • Yamada T.
      • Ramaswamy K.
      • Ahn J.
      • Kay G.N.
      Idiopathic focal epicardial ventricular tachycardia originating from the crux of the heart.
      ,
      • Kawamura M.
      • Gerstenfeld E.P.
      • Vedantham V.
      • et al.
      Idiopathic ventricular arrhythmia originating from the cardiac crux or inferior septum.
      ,
      • Larroussi L.
      • Badhwar N.
      Ventricular tachycardia arising from cardiac crux: electrocardiogram recognition and site of ablation.
      ,
      • Yui Y.
      • Sekiguchi Y.
      • Nogami A.
      • et al.
      Electrophysiological characteristics and radiofrequency catheter ablation treatment of idiopathic ventricular arrhythmias successfully ablated from the ostium of the coronary sinus.
      IIaB-NR
      • 4.
        In patients with symptomatic VAs from para-Hisian sites in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation can be useful.
      • Sasaki K.
      • Sasaki S.
      • Kimura M.
      • et al.
      Catheter ablation of ventricular arrhythmias arising from the basal septum of the right ventricle: characteristics and significance of junctional rhythm appearing during ablation.
      ,
      • Lian-Pin W.
      • Yue-Chun L.
      • Jing-Lin Z.
      • et al.
      Catheter ablation of idiopathic premature ventricular contractions and ventricular tachycardias originating from right ventricular septum.
      ,
      • Enriquez A.
      • Pathak R.K.
      • Santangeli P.
      • et al.
      Inferior lead discordance in ventricular arrhythmias: a specific marker for certain arrhythmia locations.
      ,
      • Komatsu Y.
      • Otomo K.
      • Taniguchi H.
      • et al.
      Catheter ablation of ventricular arrhythmias arising from the right ventricular septum close to the His bundle: features of the local electrogram at the optimal ablation site.
      ,
      • Yamada T.
      • Plumb V.J.
      • McElderry H.T.
      • Doppalapudi H.
      • Epstein A.E.
      • Kay G.N.
      Focal ventricular arrhythmias originating from the left ventricle adjacent to the membranous septum.
      ,
      • Wei H.Q.
      • Guo X.G.
      • Liu X.
      • et al.
      Safety and efficacy of catheter ablation of ventricular arrhythmias with para-Hisian origin via a systematic direct approach from the aortic sinus cusp.
      ,
      • Yamauchi Y.
      • Aonuma K.
      • Takahashi A.
      • et al.
      Electrocardiographic characteristics of repetitive monomorphic right ventricular tachycardia originating near the His-bundle.
      ,
      • Komatsu Y.
      • Taniguchi H.
      • Miyazaki S.
      • et al.
      Two distinct electrocardiographic forms of idiopathic ventricular arrhythmia originating in the vicinity of the His bundle.
      ,
      • Enriquez A.
      • Tapias C.
      • Rodriguez D.
      • et al.
      How to map and ablate parahisian ventricular arrhythmias.
      IIaC-LD
      • 5.
        In patients with symptomatic VAs from the posterior-superior process of the LV in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation from the LV endocardium, right atrium, or CS, can be useful.
      • Santangeli P.
      • Hutchinson M.D.
      • Supple G.E.
      • Callans D.J.
      • Marchlinski F.E.
      • Garcia F.C.
      Right atrial approach for ablation of ventricular arrhythmias arising from the left posterior-superior process of the left ventricle.
      ,
      • Li A.
      • Zuberi Z.
      • Bradfield J.S.
      • et al.
      Endocardial ablation of ventricular ectopic beats arising from the basal inferoseptal process of the left ventricle.
      ,
      • Tavares L.
      • Dave A.
      • Valderrábano M.
      Successful ablation of premature ventricular contractions originating from the inferoseptal process of the left ventricle using a coronary sinus approach.

      4.3 Premature Ventricular Complexes With or Without Left Ventricular Dysfunction

      Tabled 1Recommendations for catheter ablation of PVCs in patients with or without LV dysfunction
      CORLOERecommendationsReferences
      IB-NR
      • 1.
        In patients with cardiomyopathy suspected to be caused by frequent and predominately monomorphic PVCs and for whom AADs are ineffective, not tolerated, or not preferred for long-term therapy, catheter ablation is recommended.
      • Latchamsetty R.Y.
      • Morady M.
      • Kim F.
      • et al.
      Multicenter outcomes for catheter ablation of idiopathic premature ventricular complexes.
      ,
      • Singh S.N.
      • Fletcher R.D.
      • Fisher S.G.
      • et al.
      Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia: survival trial of antiarrhythmic therapy in congestive heart failure.
      ,
      • Mountantonakis S.E.
      • Frankel D.S.
      • Gerstenfeld E.P.
      • et al.
      Reversal of outflow tract ventricular premature depolarization-induced cardiomyopathy with ablation: effect of residual arrhythmia burden and preexisting cardiomyopathy on outcome.
      ,
      • Zang M.
      • Zhang T.
      • Mao J.
      • Zhou S.
      • He B.
      Beneficial effects of catheter ablation of frequent premature ventricular complexes on left ventricular function.
      ,
      • Lee A.
      • Denman R.
      • Haqqani H.M.
      Ventricular ectopy in the context of left ventricular systolic dysfunction: risk factors and outcomes following catheter ablation.
      ,
      • Bogun F.
      • Crawford T.
      • Reich S.
      • et al.
      Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: comparison with a control group without intervention.
      ,
      • Takemoto M.
      • Yoshimura H.
      • Ohba Y.
      • et al.
      Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract improves left ventricular dilation and clinical status in patients without structural heart disease.
      ,
      • Baman T.S.
      • Lange D.C.
      • Ilg K.J.
      • et al.
      Relationship between burden of premature ventricular complexes and left ventricular function.
      ,
      • Yarlagadda R.K.
      • Iwai S.
      • Stein K.M.
      • et al.
      Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract.
      ,
      • Wijnmaalen A.P.
      • Delgado V.
      • Schalij M.J.
      • et al.
      Beneficial effects of catheter ablation on left ventricular and right ventricular function in patients with frequent premature ventricular contractions and preserved ejection fraction.
      IIaB-NR
      • 2.
        In patients with SHD in whom frequent PVCs are suspected to be contributing to a cardiomyopathy and for whom AADs are ineffective, not tolerated, or not preferred for long-term therapy, catheter ablation can be useful.
      • Mountantonakis S.E.
      • Frankel D.S.
      • Gerstenfeld E.P.
      • et al.
      Reversal of outflow tract ventricular premature depolarization-induced cardiomyopathy with ablation: effect of residual arrhythmia burden and preexisting cardiomyopathy on outcome.
      ,
      • Sarrazin J.F.
      • Labounty T.
      • Kuhne M.
      • et al.
      Impact of radiofrequency ablation of frequent post-infarction premature ventricular complexes on left ventricular ejection fraction.
      ,
      • El Kadri M.
      • Yokokawa M.
      • Labounty T.
      • et al.
      Effect of ablation of frequent premature ventricular complexes on left ventricular function in patients with nonischemic cardiomyopathy.
      IIaB-NR
      • 3.
        In patients with focally triggered VF refractory to AADs and triggered by a similar PVC, catheter ablation can be useful.
      • Haïssaguerre M.
      • Shoda M.
      • Jaïs P.
      • et al.
      Mapping and ablation of idiopathic ventricular fibrillation.
      ,
      • Knecht S.
      • Sacher F.
      • Wright M.
      • et al.
      Long-term follow-up of idiopathic ventricular fibrillation ablation: a multicenter study.
      ,
      • Peichl P.
      • Cihák R.
      • Kozeluhová M.
      • Wichterle D.
      • Vancura V.
      • Kautzner J.
      Catheter ablation of arrhythmic storm triggered by monomorphic ectopic beats in patients with coronary artery disease.
      ,
      • Haïssaguerre M.
      • Extramiana F.
      • Hocini M.
      • et al.
      Mapping and ablation of ventricular fibrillation associated with long-QT and Brugada syndromes.
      ,
      • Sadek M.M.
      • Benhayon D.
      • Sureddi R.
      • et al.
      Idiopathic ventricular arrhythmias originating from the moderator band: electrocardiographic characteristics and treatment by catheter ablation.
      IIaC-LD
      • 4.
        In nonresponders to cardiac resynchronization therapy with very frequent unifocal PVCs limiting optimal biventricular pacing despite pharmacological therapy, catheter ablation can be useful.
      • Lakkireddy D.
      • Di Biase L.
      • Ryschon K.
      • et al.
      Radiofrequency ablation of premature ventricular ectopy improves the efficacy of cardiac resynchronization therapy in nonresponders.

      4.4 Ventricular Arrhythmia in Ischemic Heart Disease

      Tabled 1Recommendations for catheter ablation of VAs in patients with IHD
      CORLOERecommendationsReferences
      IB-R
      • 1.
        In patients with IHD who experience recurrent monomorphic VT despite chronic amiodarone therapy, catheter ablation is recommended in preference to escalating AAD therapy.
      • Sapp J.L.
      • Wells G.A.
      • Parkash R.
      • et al.
      Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs.
      IB-NR
      • 2.
        In patients with IHD and recurrent symptomatic monomorphic VT despite AAD therapy, or when AAD therapy is contraindicated or not tolerated, catheter ablation is recommended to reduce recurrent VT.
      • Stevenson W.G.
      • Wilber D.J.
      • Natale A.
      • et al.
      Multicenter Thermocool VT Ablation Trial Investigators
      Irrigated radiofrequency catheter ablation guided by electroanatomic mapping for recurrent ventricular tachycardia after myocardial infarction: the multicenter thermocool ventricular tachycardia ablation trial.
      ,
      • Tanner H.
      • Hindricks G.
      • Volkmer M.
      • et al.
      Catheter ablation of recurrent scar-related ventricular tachycardia using electroanatomical mapping and irrigated ablation technology: results of the prospective multicenter Euro-VT-study.
      ,
      • Marchlinski F.E.
      • Haffajee C.I.
      • Beshai J.F.
      • et al.
      Long-term success of irrigated radiofrequency catheter ablation of sustained ventricular tachycardia: post-approval THERMOCOOL VT trial.
      IB-NR
      • 3.
        In patients with IHD and VT storm refractory to AAD therapy, catheter ablation is recommended.
      • Carbucicchio C.
      • Santamaria M.
      • Trevisi N.
      • et al.
      Catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-defibrillators: short- and long-term outcomes in a prospective single-center study.
      ,
      • Deneke T.
      • Shin D.
      • Lawo T.
      • et al.
      Catheter ablation of electrical storm in a collaborative hospital network.
      ,
      • Muser D.
      • Liang J.J.
      • Pathak R.K.
      • et al.
      Long-term outcomes of catheter ablation of electrical storm in nonischemic dilated cardiomyopathy compared with ischemic cardiomyopathy.
      ,
      • Kumar S.
      • Fujii A.
      • Kapur S.
      • et al.
      Beyond the storm: comparison of clinical factors, arrhythmogenic substrate, and catheter ablation outcomes in structural heart disease patients with versus those without a history of ventricular tachycardia storm.
      ,
      • Nayyar S.
      • Ganesan A.N.
      • Brooks A.G.
      • Sullivan T.
      • Roberts-Thomson K.C.
      • Sanders P.
      Venturing into ventricular arrhythmia storm: a systematic review and meta-analysis.
      IIaC-EO
      • 4.
        In patients with IHD and recurrent monomorphic VT, in whom AADs are not desired, catheter ablation can be useful.
      IIbA
      • 5.
        In patients with IHD and an ICD who experience a first episode of monomorphic VT, catheter ablation may be considered to reduce the risk of recurrent VT or ICD therapies.
      • Reddy V.Y.
      • Reynolds M.R.
      • Neuzil P.
      • et al.
      Prophylactic catheter ablation for the prevention of defibrillator therapy.
      ,
      • Kuck K.H.
      • Schaumann A.
      • Eckhardt L.
      • et al.
      for the VTACH Study Group
      Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial.
      ,
      • Al-Khatib S.M.
      • Daubert J.P.
      • Anstrom K.J.
      • et al.
      Catheter ablation for ventricular tachycardia in patients with an implantable cardioverter defibrillator (CALYPSO) pilot trial.
      ,
      • Kuck K.H.
      • Tilz R.R.
      • Deneke T.
      • et al.
      SMS Investigators.
      Impact of substrate modification by catheter ablation on implantable cardioverter–defibrillator interventions in patients with unstable ventricular arrhythmias and coronary artery disease: results from the multicenter randomized controlled SMS (Substrate Modification Study).
      ,
      • Martinez B.K.
      • Baker W.L.
      • Konopka A.
      • et al.
      Systematic review and meta-analysis of catheter ablation of ventricular tachycardia in ischemic heart disease.
      IIbC-LD
      • 6.
        In patients with prior myocardial infarction and recurrent episodes of symptomatic sustained VT for whom prior endocardial catheter ablation has not been successful and who have ECG, endocardial mapping, or imaging evidence of a subepicardial VT substrate, epicardial ablation may be considered.
      • Littmann L.
      • Svenson R.H.
      • Gallagher J.J.
      • et al.
      Functional role of the epicardium in postinfarction ventricular tachycardia: observations derived from computerized epicardial activation mapping, entrainment, and epicardial laser photoablation.
      ,
      • Sosa E.
      • Scanavacca M.
      • d’Avila A.
      • Oliveira F.
      • Ramires J.A.
      Nonsurgical transthoracic epicardial catheter ablation to treat recurrent ventricular tachycardia occurring late after myocardial infarction.
      ,
      • Schmidt B.
      • Chun K.R.
      • Baensch D.
      • Antz M.
      • Koektuerk B.
      • Tilz R.R.
      • Metzner A.
      • Ouyang F.
      • Kuck K.H.
      Catheter ablation for ventricular tachycardia after failed endocardial ablation: epicardial substrate or inappropriate endocardial ablation?.
      ,
      • Di Biase L.
      • Santangeli P.
      • Burkhardt D.J.
      • et al.
      Endo-epicardial homogenization of the scar versus limited endocardial substrate ablation for the treatment of electrical storms in patients with ischemic cardiomyopathy.
      ,
      • Izquierdo M.
      • Sánchez-Gómez J.M.
      • Ferrero de Loma-Osorio A.
      • Martínez A.
      • Bellver A.
      • Peláez A.
      • Núñez J.
      • Núñez C.
      • Chorro J.
      • Ruiz-Granell R.
      Endo-epicardial versus only-endocardial ablation as a first line strategy for the treatment of ventricular tachycardia in patients with ischemic heart disease.

      4.5 Nonischemic Cardiomyopathy

      Tabled 1Recommendations for catheter ablation of VT in nonischemic cardiomyopathy (NICM)
      CORLOERecommendationsReferences
      IB-NR
      • 1.
        In patients with NICM and recurrent sustained monomorphic VT for whom antiarrhythmic medications are ineffective, contraindicated, or not tolerated, catheter ablation is useful for reducing recurrent VT and ICD shocks.
      • Muser D.
      • Santangeli P.
      • Castro S.A.
      • et al.
      Long-term outcome after catheter ablation of ventricular tachycardia in patients with nonischemic dilated cardiomyopathy.
      ,
      • Proietti R.
      • Essebag V.
      • Beardsall J.
      • et al.
      Substrate-guided ablation of haemodynamically tolerated and untolerated ventricular tachycardia in patients with structural heart disease: effect of cardiomyopathy type and acute success on long-term outcome.
      ,
      • Dinov B.
      • Arya A.
      • Bertagnolli L.
      • et al.
      Early referral for ablation of scar-related ventricular tachycardia is associated with improved acute and long-term outcomes: results from the Heart Center of Leipzig ventricular tachycardia registry.
      ,
      • Dinov B.
      • Fiedler L.
      • Schönbauer R.
      • et al.
      Outcomes in catheter ablation of ventricular tachycardia in dilated nonischemic cardiomyopathy compared with ischemic cardiomyopathy: results from the Prospective Heart Centre of Leipzig VT (HELP-VT) study.
      ,
      • Tokuda M.
      • Tedrow U.B.
      • Kojodjojo P.
      • et al.
      Catheter ablation of ventricular tachycardia in nonischemic heart disease.
      ,
      • Tung R.
      • Vaseghi M.
      • Frankel D.S.
      • et al.
      Freedom from recurrent ventricular tachycardia after catheter ablation is associated with improved survival in patients with structural heart disease: an International VT Ablation Center Collaborative Group study.
      IB-NR
      • 2.
        In patients with NICM and electrical storm refractory to AAD therapy, catheter ablation is useful for reducing recurrent VT and ICD shocks.
      • Muser D.
      • Liang J.J.
      • Pathak R.K.
      • et al.
      Long-term outcomes of catheter ablation of electrical storm in nonischemic dilated cardiomyopathy compared with ischemic cardiomyopathy.
      ,
      • Arya A.
      • Bode K.
      • Piorkowski C.
      • et al.
      Catheter ablation of electrical storm due to monomorphic ventricular tachycardia in patients with nonischemic cardiomyopathy: acute results and its effect on long-term survival.
      ,
      • Carbucicchio C.
      • Santamaria M.
      • Trevisi N.
      • et al.
      Catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-defibrillators: short- and long-term outcomes in a prospective single-center study.
      IIaB-NR
      • 3.
        In patients with NICM, epicardial catheter ablation of VT can be useful after failure of endocardial ablation or as the initial ablation approach when there is a suspicion of an epicardial substrate or circuit.
      • Dinov B.
      • Fiedler L.
      • Schönbauer R.
      • et al.
      Outcomes in catheter ablation of ventricular tachycardia in dilated nonischemic cardiomyopathy compared with ischemic cardiomyopathy: results from the Prospective Heart Centre of Leipzig VT (HELP-VT) study.
      ,
      • Hu J.
      • Zeng S.
      • Zhou Q.
      • et al.
      Can ventricular tachycardia non-inducibility after ablation predict reduced ventricular tachycardia recurrence and mortality in patients with non-ischemic cardiomyopathy? A meta-analysis of twenty-four observational studies.
      ,
      • Della Bella P.
      • Brugada J.
      • Zeppenfeld K.
      • et al.
      Epicardial ablation for ventricular tachycardia: a European multicenter study.
      ,
      • Sacher F.
      • Roberts-Thomson K.
      • Maury P.
      • et al.
      Epicardial ventricular tachycardia ablation a multicenter safety study.
      ,
      • Cano O.
      • Hutchinson M.
      • Lin D.
      • et al.
      Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy.
      IIaB-NR
      • 4.
        In patients with cardiac sarcoidosis and recurrent VT despite medical therapy, catheter ablation can be useful to reduce the risk of VT recurrence and ICD shocks.
      • Jefic D.
      • Joel B.
      • Good E.
      • et al.
      Role of radiofrequency catheter ablation of ventricular tachycardia in cardiac sarcoidosis: report from a multicenter registry.
      ,
      • Naruse Y.
      • Sekiguchi Y.
      • Nogami A.
      • et al.
      Systematic treatment approach to ventricular tachycardia in cardiac sarcoidosis.
      ,
      • Kumar S.
      • Barbhaiya C.
      • Nagashima K.
      • et al.
      Ventricular tachycardia in cardiac sarcoidosis: characterization of ventricular substrate and outcomes of catheter ablation.
      ,
      • Muser D.
      • Santangeli P.
      • Pathak R.K.
      • et al.
      Long-term outcomes of catheter ablation of ventricular tachycardia in patients with cardiac sarcoidosis.
      ,
      • Papageorgiou N.
      • Providência R.
      • Bronis K.
      • et al.
      Catheter ablation for ventricular tachycardia in patients with cardiac sarcoidosis: a systematic review.
      IIaC-EO
      • 5.
        In patients with NICM and recurrent sustained monomorphic VT for whom antiarrhythmic medications are not desired, catheter ablation can be useful for reducing recurrent VT and ICD shocks.
      IIbB-NR
      • 6.
        In patients with NICM related to lamin A/C (LMNA) mutations and recurrent VT, catheter ablation may be considered as a palliative strategy for short-term arrhythmia control.
      • Kumar S.
      • Androulakis A.F.
      • Sellal J.M.
      • et al.
      Multicenter experience with catheter ablation for ventricular tachycardia in lamin A/C cardiomyopathy.

      4.6 Ventricular Arrhythmia Involving the His-Purkinje System, Bundle Branch Reentrant Ventricular Tachycardia, and Fascicular Ventricular Tachycardia

      Tabled 1Recommendations for catheter ablation of bundle branch reentrant VT and for catheter ablation of fascicular VT
      CORLOERecommendationsReferences
      IB-NR
      • 1.
        In patients with bundle branch reentrant VT, catheter ablation is useful for reducing the risk of recurrent VT.
      • Cohen T.J.
      • Chien W.W.
      • Lurie K.G.
      • et al.
      Radiofrequency catheter ablation for treatment of bundle branch reentrant ventricular tachycardia: results and long-term follow-up.
      ,
      • Blank Z.
      • Dhala A.
      • Deshpande S.
      • Sra J.
      • Jazayeri M.
      • Akhtar M.
      Bundle branch reentrant ventricular tachycardia: Cumulative experience in 48 patients.
      ,
      • Mehdirad A.A.
      • Keim S.
      • Rist K.
      • Tchou P.
      Long-term clinical outcome of right bundle branch radiofrequency catheter ablation for treatment of bundle branch reentrant ventricular tachycardia.
      ,
      • Pathak R.K.
      • Fahed J.
      • Santangeli P.
      • et al.
      Long-term outcome of catheter ablation for treatment of bundle branch re-entrant tachycardia.
      ,
      • Narasimhan C.
      • Jazayeri M.R.
      • Sra J.
      • et al.
      Ventricular tachycardia in valvular heart disease: facilitation of bundle-branch reentry by valve surgery.
      ,
      • Li Y.G.
      • Grönefeld G.
      • Israel C.
      • Bogun F.
      • Hohnloser S.H.
      Bundle branch reentrant tachycardia in patients with apparent normal His-Purkinje conduction: the role of functional conduction impairment.
      ,
      • Schmidt B.
      • Tang M.
      • Chun K.R.
      • et al.
      Left bundle branch-Purkinje system in patients with bundle branch reentrant tachycardia: lessons from catheter ablation and electroanatomic mapping.
      ,
      • Blanck Z.
      • Jazayeri M.
      • Dhala A.
      • Deshpande S.
      • Sra J.
      • Akhtar M.
      Bundle branch reentry: a mechanism of ventricular tachycardia in the absence of myocardial or valvular dysfunction.
      ,
      • Chen H.
      • Shi L.
      • Yang B.
      • et al.
      Electrophysiological characteristics of bundle branch reentry ventricular tachycardia in patients without structural heart disease.
      IB-NR
      • 2.
        In patients with idiopathic left fascicular reentrant VT for whom medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation is useful.
      • Nogami A.
      • Naito S.
      • Tada H.
      • et al.
      Demonstration of diastolic and presystolic Purkinje potentials as critical potentials in a macroreentry circuit of verapamil-sensitive idiopathic left ventricular tachycardia.
      ,
      • Ouyang F.
      • Cappato R.
      • Ernst S.
      • et al.
      Electroanatomic substrate of idiopathic left ventricular tachycardia: unidirectional block and macroreentry within the Purkinje network.
      ,
      • Liu Y.
      • Fang Z.
      • Yang B.
      • et al.
      Catheter ablation of fascicular ventricular tachycardia: long-term clinical outcomes and mechanisms of recurrence.
      ,
      • Nakagawa H.
      • Beckman K.J.
      • McClelland J.H.
      • et al.
      Radiofrequency catheter ablation of idiopathic left ventricular tachycardia guided by a Purkinje potential.
      ,
      • Chen M.
      • Yang B.
      • Zou J.
      • et al.
      Non-contact mapping and linear ablation of the left posterior fascicle during sinus rhythm in the treatment of idiopathic left ventricular tachycardia.
      ,
      • Kottkamp H.
      • Chen X.
      • Hindricks G.
      • et al.
      Idiopathic left ventricular tachycardia: new insights into electrophysiological characteristics and radiofrequency catheter ablation.
      ,
      • Lin D.
      • Hsia H.H.
      • Gerstenfeld E.P.
      • et al.
      Idiopathic fascicular left ventricular tachycardia: linear ablation lesion strategy for noninducible or nonsustained tachycardia.
      ,
      • Tada H.
      • Nogami A.
      • Naito S.
      • et al.
      Retrograde Purkinje potential activation during sinus rhythm following catheter ablation of idiopathic left ventricular tachycardia.
      ,
      • Tsuchiya T.
      • Okumura K.
      • Honda T.
      • et al.
      Significance of late diastolic potential preceding Purkinje potential in verapamil-sensitive idiopathic left ventricular tachycardia.
      ,
      • Wen M.S.
      • Yeh S.J.
      • Wang C.C.
      • Lin F.C.
      • Wu D.
      Successful radiofrequency ablation of idiopathic left ventricular tachycardia at a site away from the tachycardia exit.
      ,
      • Arya A.
      • Haghjoo M.
      • Emkanjoo Z.
      • et al.
      Comparison of presystolic Purkinje and late diastolic potentials for selection of ablation site in idiopathic verapamil sensitive left ventricular tachycardia.
      ,
      • Liu Q.
      • Shehata M.
      • Jiang R.
      • et al.
      Macroreentrant loop in ventricular tachycardia from the left posterior fascicle: new implications for mapping and ablation.
      ,
      • Guo X.G.
      • Liu X.
      • Zhou G.B.
      • et al.
      Clinical, electrocardiographic, and electrophysiological characteristics of left upper septal fascicular ventricular tachycardia.
      IB-NR
      • 3.
        In larger pediatric patients (≥15 kg) with idiopathic left fascicular reentrant VT in whom medical treatment is ineffective or not tolerated, catheter ablation is useful.
      • Collins K.K.
      • Schaffer M.S.
      • Liberman L.
      • et al.
      Fascicular and nonfascicular left ventricular tachycardias in the young: an international multicenter study.
      ,
      • Suzuki T.
      • Nakamura Y.
      • Yoshida S.
      • et al.
      Radiofrequency catheter ablation of idiopathic left anterior fascicular ventricular tachycardia in children.
      ,
      • Fishberger S.B.
      • Olen M.M.
      • Rollinson N.L.
      • Rossi A.F.
      Creation of partial fascicular block: an approach to ablation of idiopathic left ventricular tachycardia in the pediatric population.
      ,
      • Saul J.P.
      • Kanter R.J.
      • Abrams D.
      • et al.
      PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease: developed in partnership with the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American Academy of Pediatrics (AAP), the American Heart Association (AHA), and the Association for European Pediatric and Congenital Cardiology (AEPC).
      IB-NR
      • 4.
        In patients with focal fascicular VT with or without SHD, catheter ablation is useful.
      • Ouyang F.
      • Cappato R.
      • Ernst S.
      • et al.
      Electroanatomic substrate of idiopathic left ventricular tachycardia: unidirectional block and macroreentry within the Purkinje network.
      ,
      • Talib A.K.
      • Nogami A.
      • Morishima I.
      • et al.
      Non-reentrant fascicular tachycardia: clinical and electrophysiological characteristics of a distinct type of idiopathic ventricular tachycardia.
      ,
      • Lopera G.
      • Stevenson W.G.
      • Soejima K.
      • et al.
      Identification and ablation of three types of ventricular tachycardia involving the His-Purkinje system in patients with heart disease.
      ,
      • Gonzalez R.P.
      • Scheinman M.M.
      • Lesh M.D.
      • Helmy I.
      • Torres V.
      • Van Hare G.F.
      Clinical and electrophysiologic spectrum of fascicular tachycardias.
      IB-NR
      • 5.
        In patients with postinfarction reentrant Purkinje fiber-mediated VT, catheter ablation is useful.
      • Nogami A.
      Purkinje-related arrhythmias. Part I: monomorphic ventricular tachycardias.
      ,
      • Hayashi M.
      • Kobayashi Y.
      • Iwasaki Y.K.
      • et al.
      Novel mechanism of postinfarction ventricular tachycardia originating in surviving left posterior Purkinje fibers.
      ,
      • Bogun F.
      • Good E.
      • Reich S.
      • et al.
      Role of Purkinje fibers in post-infarction ventricular tachycardia.

      4.7 Congenital Heart Disease

      Tabled 1Recommendations for catheter ablation of VA in patients with CHD
      CORLOERecommendationsReferences
      IB-NR
      • 1.
        In patients with CHD presenting with sustained VAs, evaluation for potential residual anatomical or coronary abnormalities should be performed.
      • Gatzoulis M.A.
      • Till J.A.
      • Somerville J.
      • Redington A.N.
      Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death.
      ,
      • Harrison D.A.
      • Harris L.
      • Siu S.C.
      • et al.
      Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot.
      ,
      • Knauth A.L.
      • Gauvreau K.
      • Powell A.J.
      • et al.
      Ventricular size and function assessed by cardiac MRI predict major adverse clinical outcomes late after tetralogy of Fallot repair.
      ,
      • Diller G.P.
      • Kempny A.
      • Liodakis E.
      • et al.
      Left ventricular longitudinal function predicts life-threatening ventricular arrhythmia and death in adults with repaired tetralogy of Fallot.
      ,
      • Koyak Z.
      • Harris L.
      • de Groot J.R.
      • et al.
      Sudden cardiac death in adult congenital heart disease.
      ,
      • Koyak Z.
      • de Groot J.R.
      • Bouma B.J.
      • et al.
      Sudden cardiac death in adult congenital heart disease: can the unpredictable be foreseen?.
      IB-NR
      • 2.
        In patients with CHD presenting with sustained VT in the presence of important hemodynamic lesions, treatment of hemodynamic abnormalities as feasible should be performed in conjunction with consideration for ablation.
      • Harrison D.A.
      • Harris L.
      • Siu S.C.
      • et al.
      Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot.
      ,
      • Deal B.J.
      • Scagliotti D.
      • Miller S.M.
      • Gallastegui J.L.
      • Hariman R.J.
      • Levitsky S.
      Electrophysiologic drug testing in symptomatic ventricular arrhythmias after repair of tetralogy of Fallot.
      ,
      • Oechslin E.N.
      • Harrison D.A.
      • Harris L.
      • et al.
      Reoperation in adults with repair of tetralogy of Fallot: indications and outcomes.
      ,
      • Therrien J.
      • Siu S.C.
      • Harris L.
      • et al.
      Impact of pulmonary valve replacement on arrhythmia propensity late after repair of tetralogy of Fallot.
      ,
      • Therrien J.
      • Provost Y.
      • Merchant N.
      • Williams W.
      • Colman J.
      • Webb G.
      Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair.
      ,
      • Mavroudis C.
      • Deal B.J.
      • Backer C.L.
      • Tsao S.
      Arrhythmia surgery in patients with and without congenital heart disease.
      ,
      • Adamson L.
      • Vohra H.A.
      • Haw M.P.
      Does pulmonary valve replacement post repair of tetralogy of Fallot improve right ventricular function?.
      ,
      • Miyazaki A.
      • Sakaguchi H.
      • Ohuchi H.
      • et al.
      Efficacy of hemodynamic-based management of tachyarrhythmia after repair of tetralogy of Fallot.
      ,
      • Khairy P.
      • Van Hare G.F.
      • Balaji S.
      • et al.
      PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD).
      ,
      • Lin Y.S.
      • Liu P.H.
      • Wu L.S.
      • Chen Y.M.
      • Chang C.J.
      • Chu P.H.
      Major adverse cardiovascular events in adult congenital heart disease: a population-based follow-up study from Taiwan.
      ,
      • Sabate Rotes A.
      • Connolly H.M.
      • Warnes C.A.
      • et al.
      Ventricular arrhythmia risk stratification in patients with tetralogy of Fallot at the time of pulmonary valve replacement.
      IB-NR
      • 3.
        In patients with repaired tetralogy of Fallot and sustained monomorphic VT or recurrent appropriate ICD therapy for VAs, catheter ablation is effective.
      • Gonska B.D.
      • Cao K.
      • Raab J.
      • Eigster G.
      • Kreuzer H.
      Radiofrequency catheter ablation of right ventricular tachycardia late after repair of congenital heart defects.
      ,
      • Morwood J.G.
      • Triedman J.K.
      • Berul C.I.
      • et al.
      Radiofrequency catheter ablation of ventricular tachycardia in children and young adults with congenital heart disease.
      ,
      • Zeppenfeld K.
      • Schalij M.J.
      • Bartelings M.M.
      • et al.
      Catheter ablation of ventricular tachycardia after repair of congenital heart disease: electroanatomic identification of the critical right ventricular isthmus.
      ,
      • Kriebel T.
      • Saul J.P.
      • Schneider H.
      • Sigler M.
      • Paul T.
      Noncontact mapping and radiofrequency catheter ablation of fast and hemodynamically unstable ventricular tachycardia after surgical repair of tetralogy of Fallot.
      ,
      • Kapel G.F.
      • Reichlin T.
      • Wijnmaalen A.P.
      • et al.
      Left-sided ablation of ventricular tachycardia in adults with repaired tetralogy of Fallot: a case series.
      ,
      • Kapel G.F.
      • Reichlin T.
      • Wijnmaalen A.P.
      • et al.
      Re-entry using anatomically determined isthmuses: a curable ventricular tachycardia in repaired congenital heart disease.
      ,
      • van Zyl M.
      • Kapa S.
      • Padmanabhan D.
      • et al.
      Mechanism and outcomes of catheter ablation for ventricular tachycardia in adults with repaired congenital heart disease.
      ,
      • Kapel G.F.
      • Sacher F.
      • Dekkers O.M.
      • et al.
      Arrhythmogenic anatomical isthmuses identified by electroanatomical mapping are the substrate for ventricular tachycardia in repaired tetralogy of Fallot.
      IIaB-NR
      • 4.
        In select patients with CHD and clinical episodes of sustained VT who are undergoing surgical repair of residual hemodynamic abnormalities, surgical ablation of VT guided by preoperative or intraoperative electroanatomical mapping (EAM) can be beneficial.
      • Harrison D.A.
      • Harris L.
      • Siu S.C.
      • et al.
      Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot.
      ,
      • Oechslin E.N.
      • Harrison D.A.
      • Harris L.
      • et al.
      Reoperation in adults with repair of tetralogy of Fallot: indications and outcomes.