Radiofrequency catheter ablation of ventricular tachycardia

Management of patients with ventricular tachycardia (VT) is often difficult. Drug treatment is often ineffective. Implantable defibrillators terminate episodes but do not prevent them. Radiofrequency (RF) catheter ablation offers potential arrhythmia control without the adverse effects of antiarrhythmic treatment. However, the procedure is often challenging and efficacy is less than for ablation of supraventricular tachycardias. The efficacy and safety depend on the particular type of tachycardia and its likely origin. These factors can be predicted from the underlying heart disease and the electrocardiographic characteristics of the tachycardia VTs are either polymorphic or monomorphic. Polymorphic tachycardias have a continuously changing QRS morphology, indicating a variable sequence of ventricular activation and no single site of origin. The cause is often ischaemia or drug induced QT prolongation; ablation is not an option. Monomorphic VT has a constant QRS morphology from beat to beat, indicating repetitive ventricular depolarisation in the same sequence. An arrhythmia focus or structural substrate is present that can be targeted for ablation. The QRS morphology often indicates the likely arrhythmogenic region. A left bundle branch block-like configuration in lead V1 indicates an origin in the right ventricle or the interventricular septum. A frontal plane axis that is directed inferiorly (dominant R waves in leads II, III, AVF) indicates an origin in the superior aspect of the ventricle, either the anterior wall of the left ventricle or the right ventricular outflow tract. A frontal plane axis directed superiorly indicates initial depolarisation of the inferior wall of the left or right ventricle. Dominant R waves in leads V3–V4 favour a location nearer the base of the heart than the apex. Dominant S waves in these leads favour a more apical location. The QRS morphology is an excellent guide to the arrhythmia origin when the ventricles are structurally normal, but less reliable when …