View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by AIR Universita degli studi di Milano 339 Special Article Venice Chart International Consensus Document on Ventricular Tachycardia/Ventricular Fibrillation Ablation ANDREA NATALE, M.D.,∗ ANTONIO RAVIELE, M.D.,† AMIN AL-AHMAD, M.D.,‡ OTTAVIO ALFIERI, M.D.,¶ ETIENNE ALIOT, M.D.,∗∗ JESUS ALMENDRAL, M.D.,†† GUNTER¨ BREITHARDT, M.D.,‡‡ JOSEP BRUGADA, M.D.,¶¶ HUGH CALKINS, M.D.,∗∗∗ DAVID CALLANS, M.D.,††† RICCARDO CAPPATO, M.D.,‡‡‡ JOHN A. CAMM, M.D.,¶¶¶ PAOLO DELLA BELLA, M.D.,∗∗∗∗ GERARD M. GUIRAUDON, M.D.,†††† MICHEL HAISSAGUERRE,¨ M.D.,‡‡‡‡ GERHARD HINDRICKS, M.D.,¶¶¶¶ SIEW YEN HO, M.D.,∗∗∗∗∗ KARL H. KUCK, M.D.,††††† FRANCIS MARCHLINSKI, M.D.,‡‡‡‡‡ DOUGLAS L. PACKER, M.D.,¶¶¶¶¶ ERIC N. PRYSTOWSKY, M.D.,∗∗∗∗∗∗ VIVEK Y. REDDY, M.D.,†††††† JEREMY N. RUSKIN, M.D.,‡‡‡‡‡‡ MAURICIO SCANAVACCA, M.D.,¶¶¶¶¶¶ KALYANAM SHIVKUMAR, M.D.,∗∗∗∗∗∗∗ KYOKO SOEJIMA, M.D.,††††††† WILLIAM J. STEVENSON, M.D.,‡‡‡‡‡‡‡ SAKIS THEMISTOCLAKIS, M.D.,¶¶¶¶¶¶¶ ATUL VERMA, M.D.,∗∗∗∗∗∗∗∗ and DAVID WILBER, M.D.,†††††††† for the Venice Chart members From the ∗Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA; †Cardiovascular Department, Ospedale dell’Angelo, Mestre-Venice, Italy; ‡Cardiac Arrhythmia Service, Stanford University Medical School, Stanford, USA; ¶Department of Cardiac Surgery, Ospedale San Raffaele, Milan, Italy; ∗∗Department of Cardio-Vascular Diseases, CHU de Nancy, Hopitalˆ de Brabois, Vandoeuvre-les-Nancy, France; ††Division of Cardiology, Hospital General Gregorio Maranon, Madrid, Spain; ‡‡Department of Cardiology and Angiology, University Hospital of Munster,¨ Munster,¨ Germany; ¶¶Thorax Institute-Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; ∗∗∗Department of Cardiology, The Johns Hopkins Hospital, Baltimore, MD, USA; †††Department of Medicine, Section of Cardiovascular Disease, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; ‡‡‡Department of Electrophysiology, Policlinico San Donato, San Donato Milanese, Italy; ¶¶¶Cardiac and Vascular Sciences, St. George’s Hospital Medical School, London, UK; ∗∗∗∗Cardiology Division, Centro Cardiologico Monzino, Milan, Italy; ††††Cardiac Surgery, University of Western Ontario, London, Canada; ‡‡‡‡Hopitalˆ Cardiologique du Haut Leveque, Bordeaux, France; ¶¶¶¶Heart Center, Department of Cardiology, University of Leipzig, Leipzig, Germany; ∗∗∗∗∗Cardiac Morphology Unit, Royal Brompton Hospital, London and Imperial College, London, UK; †††††Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany; ‡‡‡‡‡Department of Medicine, Section of Cardiovascular Disease, University of Pennsylvania, Philadelphia, PA, USA; ¶¶¶¶¶Cardiac Translational and Electrophysiology Laboratory, Saint Mary’s Hospital Complex, Mayo Clinic Foundation, Rochester, NY, USA; ∗∗∗∗∗∗The Care Group, Indianapolis, IN, USA; ††††††Cardiac Arrhythmia Service, Miller School of Medicine, University of Miami, Miami, USA; ‡‡‡‡‡‡Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA; ¶¶¶¶¶¶Heart Institute, University of San Paulo Medical School, San Paulo, Brazil; ∗∗∗∗∗∗∗Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; †††††††Cardiovascular Division, University of Miami Hospital, Miami USA; ‡‡‡‡‡‡‡Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA; ¶¶¶¶¶¶¶Cardiovascular Department, Ospedale dell’Angelo, Mestre-Venice, Italy; ∗∗∗∗∗∗∗∗Cardiology, Southlake Regional Health Center, Toronto, Canada; and ††††††††Department of Cardiology, Loyola University Medical Center, Chicago, IL, USA (J Cardiovasc Electrophysiol, Vol. 21, pp. 339-379, March 2010) catheter ablation, guidelines, heart failure, ventricular fibrillation, ventricular tachycardia This manuscript was processed by a guest editor. sultant: Medtronic, speaker’s bureau and honoraria: unspecified; G. Bre- ithardt, speaker’s bureau and honoraria: Boston Scientific, Medtronic; J. For the Venice Chart composition (committees, members, and affiliations) Brugada, research grant: Boston Scientific, St. Jude Medical, Biotronik; P. see the Appendix. Della Bella, honoraria: St. Jude Medical; K. Kuck, research grant: St. Jude Medical, speaker’s bureau: St. Jude Medical, Biosense Webster; F. March- This document was made possible by an Educational Grant of Biosense linski, speaker’s bureau: Medtronic, Boston Scientific, St. Jude Medical, Webster, a Johnson & Johnson Company. Biotronik, Biosense Webster, consultant/advisory board: Biosense Webster; D. Packer, research grant, honoraria, consultant/advisory board: Biosense Disclosures: A. Natale, research grant: St. Jude Medical, speaker’s bu- Webster, EPT, CryoCath, Siemens, St. Jude Medical; E. Prystowsky, hon- reau: St. Jude Medical, Boston Scientific, Biosense Webster, Medtronic; oraria, consultant/advisory board: Medtronic, stock options: Stereotaxis; A. Raviele, speaker’s bureau: Biosense Webster, consultant/advisory board: V. Reddy, research support, consultant/advisory board: Biosense Webster, Sanofi-aventis; A. Al-Ahmad, honoraria: Medtronic; J. Almendral, con- St. Jude Medical; J. Ruskin, research support: Biosense Webster, St. Jude 340 Journal of Cardiovascular Electrophysiology Vol. 21, No. 3, March 2010 Introduction Classification According to Duration Sustained ventricular arrhythmias—ventricular tachycar- (1) Premature ventricular complexes (PVC): isolated com- dia (VT) and ventricular fibrillation (VF)—are important plexes originating from the His-Purkinje system or ven- causes of morbidity and sudden death (SD), especially in tricular myocardium. patients with structural heart disease. Therapeutic options (2) VT: 3 or more consecutive QRS complexes at a rate for the treatment of these arrhythmias include antiarrhyth- greater than 100 beats per minute. mic drugs, implantable cardioverter-defibrillators (ICDs), (3) Nonsustained VT: VT that terminates spontaneously and surgical and catheter ablation. Antiarrhythmic drugs have within 30 seconds. disappointing efficacy and adverse side effects that may out- (4) Sustained VT: continuous VT lasting for ≥30 seconds weigh benefits. ICDs effectively terminate VT/VF episodes or that requires an intervention for termination (such as and represent the mainstay therapy to prevent SD. However, cardioversion). ICD shocks are painful, reduce quality of life, and predict increased risk of death and heart failure. Classification According to Morphology of QRS Catheter ablation, as therapeutic option for ventricular Complexes arrhythmias, was first proposed in 1983.1 Since then, sig- (1) Monomorphic VT: VT that has a similar QRS configu- nificant developments in ablation and mapping technolo- ration from beat to beat. Some variability in QRS mor- gies have been made. The most relevant developments phology at initiation is not uncommon. include the use of radiofrequency (RF) energy, introduc- (2) Multiple monomorphic VT: more than one morpholog- tion of steerable, large-tip, and irrigated catheters, activation ically distinct monomorphic VT, occurring as different and entrainment mapping, electroanatomic mapping with the episodes or induced at different times. possibility of performing substrate-based ablation during si- (3) Polymorphic VT: VT that has a continuously changing nus rhythm, multielectrode mapping with the possibility of QRS configuration indicating a changing ventricular ac- ablating hemodynamically unstable VT, and epicardial map- tivation sequence. ping and ablation. All these advances have contributed to (4) Pleomorphic VT: VT that has more than one morpholog- improved outcomes and to a substantial expansion in the ically distinct QRS complex occurring during the same indications of catheter ablation of ventricular arrhythmias. episode of VT, but the QRS is not continuously chang- Moreover, they have generated the need to standardize the ing. different aspects of the procedure. (5) Ventricular flutter: rapid VT that has a sinusoidal QRS Inspired by this need, the Organizers of Venice Arrhyth- configuration that prevents identification of the QRS mias 2009 assembled world-recognized experts in the field morphology. of ventricular arrhythmias to develop an international con- (6) VF: ventricular tachyarrhythmia that has a totally chaotic sensus document on VT/VF ablation. In this article, the work morphology. produced by this group of experts is reported. Classification According to Clinical Characteristics Definition, Classification, and Clinical (1) Clinical VT: VT that has occurred spontaneously based Presentation of VT/VF on analysis of 12-lead ECG QRS morphology and rate. Definition (2) Hemodynamically unstable VT: VT that causes hemo- dynamic compromise requiring prompt termination. Ventricular arrhythmias are defined as arrhythmias that (3) Incessant VT: continuous sustained VT that recurs im- originate below the bifurcation of His bundle, in the special- mediately despite repeated spontaneous or therapeutic ized conduction system, the ventricular muscle, or in combi- termination. nation of both tissues. (4) Repetitive monomorphic VT: continuously repeating There are different classifications of ventricular arrhyth- episodes of self terminating nonsustained VT. mias, according to their duration, morphology of QRS com- (5) VT storm: 3 or more separate episodes of sustained VT plexes, and clinical characteristics. within 24 hours, each requiring termination by an inter- vention. (6) Unmappable VT: VT that does not allow interrogation Medical, honoraria: Boston Scientific, St.