Consensus: More trials needed on catheter ablation of ventricular arrhythmias

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BOSTON--A call to action for more research into catheter ablation in the field of ventricular arrhythmia (VA) has been released today in a joint consensus document from the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS) at the 30th annual scientific sessions of the HRS meeting held in Boston.

The consensus provides an up-to-date review of indications, techniques and outcomes of ablation for treatment of VAs.

“Over the past several years, there has been a progress with catheter ablation, but a bit less focus and literature on ventricular arrhythmias, so our goal was to bring it into a common document,” U.S. co-chair William G. Stevenson, MD, from Brigham & Women's Hospital in Boston, said at a press conference this morning.

"In the last few years there has been a substantial evolution of techniques for catheter ablation in VA. We hope this document will help identify the areas in catheter ablation that require further research, and encourage clinicians to embark on more clinical and registry studies," said Etienne Aliot, the European co-chair from Nancy, France. "It is only by conducting more clinical trials and registries that we can begin to get an idea of exactly how catheter ablation fits into the whole VA treatment paradigm including ICDs and antiarrhythmic drugs."

The document, authored by 20 European and U.S. electrophysiologists, recognizes there is still "very limited" data establishing the long-term impact of catheter ablation on morbidity and mortality.

Unanswered questions highlighted by the joint document include:

  • The long term efficacy of catheter ablation;
  • The comparative success rates of drug and ablative therapies;
  • Can ablation slow the progression of ventricular remodeling in structural heart disease; and
  • Patient definition with different underlying cardiac and non-cardiac diseases.

"Over the past decade there has been great progress with important advances in methods for mapping and ablating ventricular arrhythmias, but there are also many gaps in our knowledge where more work is needed. EHRA and HRS recognized that a document summarizing where we are now, where there is agreement and where we need to go would be timely and important," Stevenson said.

Despite the advances, Aliot and Stevenson agreed the standard of care for this patient population is to first have the patient start taking at least one antiarrhythmic drug therapy, before they undertake catheter ablation. Aliot added that many patients have contraindications to these drugs, and they are often ineffective.

VA ablation is an area with few clinical trials, but many single-center reports. The consensus summarized the opinion of task force members based on their own experience of treating patients, in addition to a review of the literature. For each topic, two members of the task force drafted a discussion document that was then considered and edited by all members of the team.

The document examines indications, outcomes and contraindications of catheter ablation, which are important concerns for physicians and their patients with ventricular arrhythmias that require treatment. Also, specific technical aspects of ablation procedures important for electrophysiologists are discussed including methods for mapping to identify ablation targets, roles for newer technologies, the use of anticoagulation, analgesia and anesthesia, and antiarrhythmic drug management. The knowledge base that physicians need, and the support staff and equipment required, are also considered.