Good afternoon. I'd like to start by expressing my gratitude for being included in this important effort and to tell you that it was my pleasure to work with Drs. Cronin and Bogan and the rest of the writing committee. I think our work together produced an outstanding document. So as you heard, my task this afternoon is to go over some of the indications for ablation of ventricular arrhythmias. And before I do so, I would like to take a minute or two to talk about the methodology that we adopted in creating this document. So as you heard, this was actually a collaborative effort among HRS, APHRS, LAHRS, ACC, AHA, JHRS, PACES, and SOBRAC. I mean, you can't be more inclusive than that. Recommendations were drafted by members who did not have relevant RWI. Members of the writing committee conducted comprehensive literature searches of different electronic databases, and they created evidence tables based on their literature search. These evidence tables were discussed during regular conference calls that we had, during which we had discussions, and those were really very informative and were able to achieve consensus on the recommendations. Unique to this consensus statement is the systematic review commissioned specifically for this document as part of HRS's efforts to adopt rigorous methodology required for guideline development. The systematic review was performed by an evidence-based practice committee based at the University of Connecticut, and it examined the question of VT ablation versus control, which is basically anti-arrhythmic medications in patients presenting with ventricular tachycardia and ischemic heart disease. So before we delve into the indications, I'd like to review with you the classification system that we use, that we've used in different guideline documents, and this is a system that provides a class of recommendation as well as a level of evidence, and I feel from my experience that people tend to confuse the two. The class of recommendation is actually a reflection of weighing the benefits against the risks, such that if the benefits outweigh the risks by a lot, then that recommendation is given a class 1 designation. A class 2A is when the benefit in most cases outweighs the risks, and then the class 2B is really in a gray zone where you're not sure about whether the benefits outweigh the risks, and of course you have class 3 indications where either there's no benefit or there may be harm, and so important to keep that in mind. Then you have the level of evidence, and that is really a reflection of how robust or rigorous the evidence that was used to develop that particular recommendation, and so you can have a level A if the evidence was generated by well-designed and conducted randomized clinical trials. You may have a level BR if you got the evidence from moderate quality randomized clinical trials, BNR observational data, but not randomized, but also of moderate quality, and then you go to level CLD where the quality of the data is not that great, and then finally CEO, and that's where you try to achieve consensus based on expert opinion. So with that background, I'm going to walk you through some of the indications in the documents, starting with idiopathic outflow tract ventricular arrhythmias. We tell you that in patients with frequent and symptomatic PVCs originating from the RVOT in an otherwise normal heart, catheter ablation is recommended in preference to medical therapy. So that got a class of recommendation 1, and then it's still focused on idiopathic outflow tract ventricular arrhythmias. We have another class of recommendation 1 in patients with symptomatic ventricular arrhythmias from the RVOT in an otherwise normal heart for whom antiarrhythmic medications are ineffective, not tolerated, or not desired, catheter ablation is useful. And then we have a couple of class 2a recommendations where we tell you that in patients with symptomatic ventricular arrhythmias from the endocardial LVOT, including the sinus of Valsalva, again in an otherwise normal heart for whom antiarrhythmic medications again are not effective, not tolerated, not the patient's preference, catheter ablation can be useful. And then in patients with symptomatic ventricular arrhythmias from the epicardial outflow tract or left ventricular summit for whom antiarrhythmic medications are ineffective, not tolerated, or not preferred, catheter ablation can be useful. So moving on to idiopathic sustained monomorphic ventricular tachycardia, we have a class of recommendation 1 here in patients with idiopathic symptomatic sustained monomorphic ventricular tachycardia, catheter ablation is useful. And then we have idiopathic non-outflow tract ventricular arrhythmias. I'm not going to read all of these indications, but just to highlight the main ones, certainly I refer you to the document. So one of the recommendations is that in patients with symptomatic ventricular arrhythmias from the right ventricle at sites other than the outflow tracts for whom an antiarrhythmic medication is not effective, not tolerated, not preferred, catheter ablation is useful. And you have another class 1 recommendation in patients with symptomatic ventricular arrhythmias from the posterior superior process of the left ventricle for whom, again, medications are either not effective, not tolerated, not preferred, catheter ablation from the right atrium is useful. And then in patients with symptomatic ventricular arrhythmias from the left ventricle, again, at sites other than the outflow tract in an otherwise normal heart, ablation is useful. And then we have this class 2A recommendation where we're focused on patients with symptomatic ventricular arrhythmias from the epicardial coronary venous system in an otherwise normal heart, catheter ablation can be useful. So switching now to PVCs with or without LV dysfunction. We tell you that in patients with cardiomyopathy that is suspected to be caused by frequent and predominantly monomorphic PVCs where antiarrhythmic drugs, again, are not effective, not tolerated, or not preferred, catheter ablation is recommended, a class 1 recommendation here. And then we have a list of different class 2A indications that tackle patients with structural heart disease in whom frequent PVCs are suspected to be contributing to cardiomyopathy, catheter ablation can be useful. And patients with focally triggered VF refractory to medical therapy and triggered by a similar PVC morphology, catheter ablation can be useful. And then in non-responders to CRT with very frequent unifocal PVCs limiting the percentage of effective BIV pacing. Despite trying medical therapy, catheter ablation can be useful. This is actually a scenario that arises pretty frequently these days. Switching gears now to talk about ventricular arrhythmias in ischemic heart disease. And those are indeed the most commonly encountered ventricular arrhythmias, at least in our practice. So starting with this class 1 recommendation in patients with ischemic heart disease who experience recurrent monomorphic ventricular tachycardia despite being on chronic amiodarone therapy, catheter ablation is recommended in preference to escalating antiarrhythmic drug therapy. This was based on the VANISH trial. And then we have a class 1 recommendation related to patients with ischemic heart disease and recurrent symptomatic monomorphic VT despite medical therapy or when the medical therapy is contraindicated, catheter ablation is recommended to reduce recurrent ventricular tachycardia. And then in patients with ischemic heart disease and VT storm refractory to antiarrhythmic drug therapy, we tell you catheter ablation is recommended. A class 2a indication relates to patients with ischemic heart disease and recurrent monomorphic ventricular tachycardia in whom antiarrhythmic drugs are not desired, then catheter ablation can be useful. An important class 2b recommendation here is when we talk about patients with ischemic heart disease and an ICD who experience a first episode of monomorphic ventricular tachycardia, we tell you catheter ablation may be considered to reduce the risk of recurrent VT or ICD therapies. And I said it's important because that's what the VANISH 2 trial is trying to address. Now moving on to patients with non-ischemic cardiomyopathy. So we tell you that in patients with non-ischemic cardiomyopathy and recurrent sustained monomorphic VT for whom antiarrhythmic medications are ineffective, not tolerated, contraindicated, catheter ablation is useful. Then we have another class 1 recommendation in patients with non-ischemic cardiomyopathy and electrical storm, refractory to medical therapy, catheter ablation is useful. And then we have a different class 2a recommendations that you can see here. I'm not going to delve into the rest of these recommendations. Bundled branch reentrant ventricular tachycardia, we have a class 1 recommendation on that. In patients with bundled branch reentrant ventricular tachycardia, catheter ablation is useful for reducing the risk of recurrent ventricular tachycardia. And we have different recommendations related to fascicular VT. You can see that we actually did our best to address almost everything that you could potentially encounter in your clinical practice. All of these are class 1 recommendations. And you have one related to patients with idiopathic left fascicular VT in whom medications are not effective, not tolerated, or not preferred. Catheter ablation is useful. We have one on larger pediatric patients with idiopathic left fascicular VT. Catheter ablation is useful. And then in patients with focal fascicular VT, with or without structural heart disease, catheter ablation is useful. And then finally, in patients with post-infarction Purkinje fiber-mediated VT, catheter ablation is useful. And then we have this list of recommendations related to congenital heart disease. So if you actually take care of a lot of these patients, this is a good resource for you. Again, in the interest of time, I'm not going to read these recommendations. Moving on to inherited arrhythmia syndromes, obviously this is an expanding area for us in the field of VT ablation. So we have a one class one recommendation. We say that in patients with ARVC who have failed one or more attempts at endocardial VT catheter ablation, an epicardial approach for VT ablation is recommended. And then we have a couple of class 2A recommendations related to patients with ARVC who experience recurrent sustained VT or frequent appropriate ICD therapies in whom, again, antiarrhythmic drug therapy is not effective, not tolerated, catheter ablation is reasonable. And then our other class 2A recommendation involves patients with Brugada syndrome who experience recurrent sustained ventricular arrhythmias or frequent appropriate ICD interventions where we tell you that ablation can be useful. And finally, this recommendation related to patients with hypertrophic cardiomyopathy in patients with HCM and recurrent monomorphic VT in whom antiarrhythmic drug therapy is ineffective or not tolerated, catheter ablation can be useful. I'd like to bring a couple of points to your attention. These recommendations are actually based on the following. The procedure is being carried out by an electrophysiologist with appropriate training and experience in the procedure in a facility with appropriate resources and that the patient and procedural complexity vary widely and some patients or situations may merit a more experienced operator or center even within the same recommendation. We also emphasize that the patient has to be an appropriate candidate for the procedure. They don't have any major contraindications in other words and that the patient's informed consent values going back to this concept of shared decision making and taking into account their overall clinical trajectory are fundamental to a decision to proceed or not to proceed with any procedure and really highlighting that in some clinical scenarios initiation or continuation of medical therapy instead of an ablation procedure may be the most appropriate approach for that particular patient. So I have no doubt that this document will have a great positive impact on patients life and I'd like to end with this quote that really reminds me of the great work that we did together. We make a living by what we get. We make a life by what we give. Thank you very much.

ablation of ventricular arrhythmias

indications

collaborative effort

patient suitability

individualized treatment plans