In patients who present with MMVT, should we perform catheter ablation first and then ICD or just implant an ICD?

Highlights

• From a practical standpoint, it is often difficult to perform a VT ablation in patients presenting with MMVT, frequently leading to ICD implantation first.
• If the clinical situation allows, the best approach is to ablate the VT to prevent inevitable shocks that occur with VT recurrence.

Expert Insights

The Ideal Versus the Practical in MMVT Management

For patients presenting with monomorphic ventricular tachycardia (MMVT), the optimal initial management strategy—specifically, the sequencing of catheter ablation and implantable cardioverter-defibrillator (ICD) implantation—remains a key clinical consideration. The decision is often framed as a choice between proactively treating the arrhythmogenic substrate to prevent future events versus establishing a safety net with an ICD first. Expert opinion suggests this choice is heavily influenced by the practical realities of the clinical presentation.

Prioritizing Ablation to Mitigate Shocks

When circumstances align favorably, the preferred approach is to perform catheter ablation prior to or in conjunction with ICD implantation. Dr. William Sauer, a specialist in cardiac electrophysiology, advocates for this strategy as the best course of action when feasible. The primary rationale, as he explains, is to prevent the shocks that would "inevitably occur when the VT recurs." By ablating the VT circuit upfront, clinicians can address the underlying electrical abnormality directly, potentially reducing the patient's future arrhythmia burden and avoiding the significant morbidity, anxiety, and negative impact on quality of life associated with ICD shocks.

"The best approach is probably to ablate the VT to avoid shocks that would inevitably occur when the VT recurs." Dr. William Sauer

Clinical Constraints on Initial Ablation

Despite the clear benefits of an ablation-first strategy, its implementation is not always straightforward. Dr. William Sauer emphasizes a critical in-clinic insight: "From a practical standpoint, it's often difficult to perform a VT ablation in someone who presents in this manner." The acute clinical scenario—which may involve hemodynamic instability, recent myocardial infarction, or other comorbidities—can render the patient a suboptimal candidate for a lengthy and complex ablation procedure at the time of initial presentation. These logistical and clinical barriers often dictate the course of management.

"From a practical standpoint, it's often difficult to perform a VT ablation in someone who presents in this manner." Dr. William Sauer

The Common Pathway: ICD Implantation with Monitoring

Given the challenges of performing an immediate ablation, the more common clinical pathway involves implanting a defibrillator and subsequently monitoring the patient. Dr. Sauer notes that clinicians are frequently "forced to simply implant a defibrillator and then monitor the patient during the follow-up period." This approach prioritizes the immediate prevention of sudden cardiac death, establishing a reliable therapy for terminating potentially life-threatening arrhythmias. The management plan then shifts to a reactive one, where an ablation may be considered later if the patient experiences recurrent VT or ICD shocks. This strategy, while pragmatic, accepts the likelihood of future device therapies and their associated consequences.