Ventricular tachycardia ablation: moving beyond treatment of last resort.

The use of ventricular tachycardia (VT) ablation in patients with structural heart disease remains reserved primarily for those who experience repeated implantable cardioverter defibrillator shocks despite pharmacological and attempted pacing therapy. This fact is confirmed by the comprehensive 8-year report of the experience with VT ablation by the group from the Brigham and Womens’ Hospital.1 Even at this very experienced center, most patients with VT in the setting of structural heart disease who were referred for catheter ablation had an implantable cardioverter defibrillator (80%), and most patients (75%) were experiencing recurrent shocks in the week before ablation, with VT storm in 30%. The group with structural heart disease failed a mean of 3 antiarrhythmic drugs, and the overwhelming majority of patients—84% in the ischemic cardiomyopathy group and 59% in the nonischemic cardiomyopathy (NICM) group—were treated with amiodarone. This tendency to “hold back” on catheter ablation therapy for VT seems to be even more dramatic as a current practice standard than previously noted. In our own institutional experience, when comparing the clinical characteristics of consecutive patients referred for VT ablation with coronary disease over a comparable time period from the mid-1990s with the current decade (Table), we observed a significant increase in the use of implantable cardioverter defibrillator therapy and amiodarone before ablation.2 Patients also appear to have poorer left ventricular function as indexed by a decline in left ventricular ejection fraction.