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(Circulation. 2008;118:2773-2782.)
© 2008 American Heart Association, Inc.

Arrhythmia/Electrophysiology

Irrigated Radiofrequency Catheter Ablation Guided by Electroanatomic Mapping for Recurrent Ventricular Tachycardia After Myocardial Infarction

The Multicenter Thermocool Ventricular Tachycardia Ablation Trial

William G. Stevenson, MD; David J. Wilber, MD; Andrea Natale, MD; Warren M. Jackman, MD; Francis E. Marchlinski, MD; Timothy Talbert, MD; Mario D. Gonzalez, MD; Seth J. Worley, MD; Emile G. Daoud, MD; Chun Hwang, MD; Claudio Schuger, MD; Thomas E. Bump, MD; Mohammad Jazayeri, MD; Gery F. Tomassoni, MD; Harry A. Kopelman, MD; Kyoko Soejima, MD; Hiroshi Nakagawa, MD, for the Multicenter Thermocool VT Ablation Trial Investigators

From the Brigham and Women’s Hospital, Boston, Mass (W.G.S., K.S.); Loyola University Medical Center, Maywood, Ill (D.J.W.); Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin (A.N.); University of Oklahoma, Oklahoma City (W.M.J., H.N.); Hospital of the University of Pennsylvania, Philadelphia (F.E.M.); Diagnostic Cardiology Group, Parkridge Medical Center, Chattanooga, Tenn (T.T.); Penn State Heart and Vascular Institute, Hershey (M.D.G.); Lancaster Heart Foundation, Lancaster, Pa (S.J.W.); Ohio State University Medical Center, Columbus (E.G.D.); Utah Valley Medical Center, Provo (C.H.); Henry Ford Hospital, Detroit, Mich (C.S.); Christ Hospital, Oak Lawn, Ill (T.E.B.); Bellin Memorial Hospital, Green Bay, Wis (M.J.); Central Baptist Hospital, Lexington, Ky (G.F.T.); and Piedmont Heart Institute, Atlanta, Ga (H.A.K.). Dr Soejima is currently at the University of Miami School of Medicine, Miami, Fla.

Correspondence to William G. Stevenson, MD, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA 02115. E-mail wstevenson{at}partners.org

Received April 24, 2008; accepted August 22, 2008.

Background— Recurrent ventricular tachycardia (VT) is an important cause of mortality and morbidity late after myocardial infarction. With frequent use of implantable cardioverter-defibrillators, these VTs are often poorly defined and not tolerated for mapping, factors previously viewed as relative contraindications to ablation. This observational multicenter study assessed the outcome of VT ablation with a saline-irrigated catheter combined with an electroanatomic mapping system.

Methods and Results— Two hundred thirty-one patients (median LV ejection fraction, 0.25; heart failure in 62%) with recurrent episodes of monomorphic VT (median, 11 in the preceding 6 months) caused by prior myocardial infarction were enrolled. All inducible monomorphic VTs with a rate approximating or slower than any spontaneous VTs were targeted for ablation guided by electroanatomic mapping during sinus rhythm and/or VT. Patients were not excluded for multiple VTs (median, 3 per patient) or unmappable VT (present in 69% of patients). Ablation abolished all inducible VTs in 49% of patients. The primary end point of freedom from recurrent incessant VT or intermittent VT after 6 months of follow-up was achieved for 123 patients (53%). In 142 patients with implantable cardioverter-defibrillators before and after ablation for intermittent VT who survived 6 months, VT episodes were reduced from a median of 11.5 to 0 (P<0.0001). The 1-year mortality rate was 18%, with 72.5% of deaths attributed to ventricular arrhythmias or heart failure. The procedure mortality rate was 3%, with no strokes.

Conclusions— Catheter ablation is a reasonable option to reduce episodes of recurrent VT in patients with prior myocardial infarction, even when multiple and/or unmappable VTs are present. This population remains at high risk for death, warranting surveillance and further study.

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CLINICAL PERSPECTIVE

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