HRS Consensus on Catheter Ablation of Ventricular Arrhythmias

Debra L Beck

May 17, 2019

SAN FRANCISCO — The Heart Rhythm Society (HRS) has released a new consensus statement on catheter ablation of ventricular arrhythmias, with more focus on treatment of individual arrhythmias, preprocedural imaging and multielectrode mapping, substrate mapping and substrate-based ablation, among other topics.

The European Heart Rhythm Association (EHRA) and HRS first issued an Expert Consensus on Catheter Ablation of Ventricular Arrhythmias in 2009, which outlined recommendations and best practices for the catheter ablation procedure.

The 2019 document updates the 2009 EHRA/HRS statement, but is also intended to supplement the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.

The full document, released during the HRS 2019 Scientific Sessions, was published online May 10 in Heart Rhythm (along with an executive summary), the official journal of the HRS; EP Europace, a journal of the European Society of Cardiology; and the Journal of Arrhythmia, the official journal of the Japanese Heart Rhythm Society and the Asia Pacific Heart Rhythm Society.

"There's been a lot of work done — mostly observational studies, but also some important randomized trials — in many areas of electrophysiology that now allow us to make some higher level-of-evidence recommendations in several areas, so this document is useful in that it pulls together all of that new information," Edmond M. Cronin, MD, cardiac electrophysiologist, Hartford HealthCare Heart and Vascular Institute, Connecticut, and the chair of the consensus statement writing committee, said in an interview.

The consensus document relies on a new systematic review and meta-analysis of catheter ablation of ventricular tachycardia in ischemic heart disease, an effort for which Cronin served as senior author.

Whereas the 2009 document laid out general recommendations for ablation procedures, it didn't really break them down by the particular disease or substrate, he explained. However, evidence collected in the past decade allowed the authors to offer more specific guidance.

"So, for example, our recommendations for ablation in ischemic cardiomyopathy are now different from our recommendations for nonischemic cardiomyopathy, which are different from the recommendations for Brugada syndrome, paying attention to the specific evidence of the substrate for each recommendation," Cronin told theheart.org | Medscape Cardiology.

In some cases, the new information reflects new technology; multielectrode mapping wasn't available when the 2009 consensus statement was written, but became available shortly after. The 2019 statement includes this technology and the substantial amount of experience that has been gained with these catheters in the past decade, said Cronin.

"We tried to make this consensus statement as methodologically rigorous and guideline-like as possible," said Cronin. "Ablation of ventricular tachycardias is a large chunk of the work being done in EP labs around the world, but it's also really the only area where there are multiple randomized controlled trials to inform us."

Keeping with the times, the document is also mobile friendly. "We use this 'knowledge bite' format where the recommendations and supportive text and references are all in one place, rather than having a big, long reference list at the end of the document. This recognizes that, particularly when we use these documents on tablets and phones, it's impractical to be flipping all the way to the end of the document to find reference number 850," said Cronin.

Global Solidarity in EP

In a time when it seems there is little agreement to be found across borders, the new consensus statement is a truly global effort. The writing group comprised 38 experts from international organizations, including the European Heart Rhythm Association, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

The document was also written with collaboration and endorsement from the American College of Cardiology, the American Heart Association, the Japanese Heart Rhythm Society, the Pediatric and Congenital Electrophysiology Society, and the Sociedade Brasileira de Arritmias Cardíacas.

The international nature of the effort is a point of pride for Cronin and the writing group members.

"We really had the whole world involved, except for Africa, where at the time this was proposed there wasn't really an EP society and not much in the way of EP services either," Cronin said. "But it's changing and there is now an EP society in sub-Saharan Africa, which hopefully will participate in future documents."

Cronin reported no conflict of interest.

Heart Rhythm. Published online May 10, 2019. Full text, Executive summary

Heart Rhythm Society (HRS) 2019 Scientific Sessions. Presented May 10, 2019.

 

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