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VT Ablation for Recurrent ICD Therapies — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyVT Ablation for Recurrent ICD TherapiesEECC

A 60-year-old man with an ICD has 12 appropriate ATP (anti-tachycardia pacing) therapies in the last month for recurrent monomorphic VT. He is on amiodarone 200 mg daily. What is the next management step?

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Correct answer: C — Referral for catheter ablation of the VT substrate — recurrent monomorphic VT despite antiarrhythmic therapy is a recommended indication for catheter ablation to reduce VT burden and ICD therapies

Recurrent monomorphic VT triggering frequent ICD therapies (ATP or shocks) despite antiarrhythmic drug therapy is a recommended indication for catheter ablation. The 2022 ESC VA/SCD Guidelines recommend VT ablation for: (1) recurrent sustained VT despite AAD (or if AAD is not tolerated/desired); (2) electrical storm refractory to AAD; (3) incessant VT. The VANISH trial demonstrated that catheter ablation was superior to escalation of AAD for reducing VT recurrence. VT ablation in ischaemic cardiomyopathy targets scar-related re-entrant circuits — substrate-based ablation (identifying and ablating the critical isthmus within scar) has success rates of 60-80% for VT elimination. While ATP itself is painless (unlike shocks), frequent ATP delivery indicates significant VT burden warranting definitive treatment.

Reference: NICE guidance: Cardiovascular conditions: https://www.nice.org.uk/guidance/conditions-and-diseases/cardiovascular-conditions