The challenge of optimising ablation lesions in catheter ablation of ventricular tachycardia

Radiofrequency catheter ablation has become an established treatment for ventricular tachycardia. The exponential increase in procedures has provided further insights into mechanisms causing arrhythmias and identification of ablation targets with the development of new mapping strategies. Since the definition of criteria to identify myocardial dense scar, borderzone and normal myocardium, and the description of isolated late potentials, local abnormal ventricular activity and decrementing evoked potential mapping, substrate-guided ablation has progressively become the method of choice to guide procedures. Accordingly, a wide range of ablation strategies have been developed from scar homogenization to scar dechanneling or core isolation using increasingly complex and precise tools such as multipolar or omnipolar mapping catheters. Despite these advances long-term success rates for VT ablation have remained static and lower in nonischemic than ischemic heart disease because of the more patchy distribution of myocardial scar. Ablation aims to deliver an irreversible loss of cellular excitability by myocardial heating to a temperatures exceeding 50 degrees C. Many indicators of ablation efficacy have been developed such as contact force, impedance drop, force-time integral and ablation index, mostly validated in atrial fibrillation ablation. In ventricular procedures there is limited data and ablation lesion parameters have been scarcely investigated. Since VT arrhythmia recurrence can be related to inadequate RF lesion formation, it seems reasonable to establish robust markers of ablation efficacy.