Review
Catheter Ablation of Recurrent Ventricular Fibrillation: A Literature Review and Case Examples

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Ventricular fibrillation (VF) electrical storm is a serious and life-threatening event, and is often triggered by premature ventricular complexes (PVCs). Catheter ablation of these PVC triggers have been described in a variety of clinical situations, including post-myocardial infarction (MI), patients with structurally normal heart, as well as in patients with Brugada Syndrome and Long QT Syndrome. We provide a literature review on this topic, using case examples for illustration.

Introduction

Ventricular fibrillation (VF) electrical storm is a rare but life-threatening event. It is often “triggered” by premature ventricular complexes (PVCs) falling in the “vulnerable” period, and has been reported to occur in a spectrum of clinical scenarios, including post-myocardial infarction patients [1], [2], as well as in patients with a structurally normal heart [3], [4] and in patients with Brugada Syndrome and Long QT Syndrome [5]. Although anti-arrhythmic therapies have been recommended for treatment of this disorder, the mortality from VF storm remains high. More recently, elimination of these PVC triggers using radiofrequency (RF) ablation has been reported to be successful in treating VF storm [2], [3], [4], [5], [6]. Here, we provide a literature review on this topic, using case examples involving patients with different underlying cardiac substrates successfully treated with catheter ablation for their recurrent VF for illustrative purposes (summarised in Table 1).

Section snippets

Case 1

A 40-year-old female presented with recurrent syncope. There was no family history of premature sudden death or arrhythmias. Although ambulatory electrocardiogram (ECG) monitoring showed infrequent PVCs (<20 over 24 hours), there were occasional episodes of non-sustained polymorphic ventricular tachycardia (VT). The initiating PVCs had a morphology suggestive of origin near the left posterior fascicle and they were closely coupled to the preceding QRS complex (coupling interval ∼320 ms; Figure 1A)

Case 2

A 24-year-old female presented following an out-of-hospital cardiac arrest. There was no history of syncope or family history of premature cardiac death. Structural heart disease was excluded by echocardiogram and MRI. Flecainide testing, adrenaline testing and exercise stress testing were normal. An ECG showed sinus rhythm with monomorphic PVCs and runs of non-sustained VT (Figure 2A). She had further monitored episodes of VF (Figure 2B). The QRS morphology of the PVCs suggested a right

Case 3

A 64-year-old female was admitted to hospital with a late presentation anteroseptal ST segment elevation myocardial infarction (MI) complicated by cardiogenic shock. Urgent coronary angiography revealed diffuse triple vessel disease not amendable to percutaneous coronary intervention. Echocardiography revealed moderate to severe left ventricular dysfunction. The patient subsequently underwent urgent coronary artery bypass grafting.

Her early postoperative course was notable for frequent

Case 4

A 64-year-old male, with a history of chronic ischaemic cardiomyopathy and severe LV dysfunction (ejection fraction 30%), presented with syncope and documented polymorphic VT/VF. Despite treatment with intravenous amiodarone and lignocaine, the patient experienced 10 further episodes of sustained polymorphic VT/VF over the next 3 days. The ventricular arrhythmias appeared to be triggered by two distinct monomorphic PVCs (right bundle branch block [RBBB] morphology with superior and inferior

Discussion

Ventricular fibrillation electrical storm is a rare but life-threatening event. Catheter ablation for treatment of recurrent PVC-triggered VF was first described by Haïssaguerre et al. in 2002 in a group of patients with structurally normal hearts [3]. It is thought that the VF was “triggered” by short-coupled PVCs falling in the “vulnerable period”, leading to R-on-T phenomenon and consequently VT or VF. It is therefore logical that eradication of these PVC triggers may eliminate the episodes

Acknowledgements

Sections of Cases 1 and 2 have been published in Heart Rhythm Case Reports and International Journal of Cardiology respectively [31], [32].

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    © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.