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EXPRESS PUBLICATION

Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy

^* Section of Cardiovascular Electrophysiology, Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received February 2, 2004; revised manuscript received February 26, 2004, accepted March 2, 2004.

^* Reprint requests and correspondence: Dr. Andrea Natale, Co-Section Head of Pacing and Electrophysiology, Director Electrophysiology Laboratory, Co-Chairman Center for Atrial Fibrillation, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F 15, Cleveland, Ohio 44195, USA.
natalea{at}ccf.org

OBJECTIVES: We report on the initiation of ventricular fibrillation (VF) storm in patients with ischemic cardiomyopathy (ICM) and the results of targeted ablation to treat VF storm.

BACKGROUND: Monomorphic premature ventricular contractions (PVCs) have been shown to initiate VF in patients without structural heart disease.

METHODS: A total of 29 patients with ICM and documented VF initiation were identified. In 21 patients, VF storm was controlled with antiarrhythmic drugs and/or treatment of heart failure. Eight patients with VF (mean 52 ± 25 episodes) refractory to medical management required ablation. All patients underwent three-dimensional electroanatomical mapping using CARTO (Biosense-Webster Inc., Diamond Bar, California), and PVCs were mapped when present. Scarred areas were identified using voltage mapping.

RESULTS: Monomorphic PVCs initiated VF in all 29 identified patients. Five of eight patients requiring ablation had frequent PVCs that allowed PVC mapping. The earliest activation site was consistently located in the scar border zone. The PVCs were always preceded by a Purkinje-like potential (PLP). Ablation was successfully performed at these sites. In three patients, infrequent PVCs prevented mapping, but PLPs were recorded around the scar border. Ablation targeting these potentials along the scar border was successfully performed. During follow-up (10 ± 6 months), one patient had a single VF episode and another developed sustained, monomorphic ventricular tachycardia. There was no recurrence of VF storm.

CONCLUSIONS: Ventricular fibrillation in ICM is triggered by monomorphic PVCs originating from the scar border zone with preceding PLPs; targeting these PVCs may prevent VF recurrence. In the absence of PVCs, both substrate mapping and ablation appear to be equally effective.

Abbreviations and Acronyms   ICD = implantable cardioverter-defibrillator   ICM = ischemic cardiomyopathy   LVAD = left ventricular assist device   MI = myocardial infarction   PLP = Purkinje-like potential   PVC = premature ventricular contraction   RF = radiofrequency   VF = ventricular fibrillation   VT = ventricular tachycardia

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