Ventricular arrhythmias in heart failure with reduced ejection fraction.

PURPOSE OF REVIEW: To provide a framework for approaching ventricular arrhythmias in the setting of cardiomyopathy, outline the latest evidence-based recommendations for catheter ablation and device therapy, and discuss novel treatment strategies. RECENT FINDINGS: Risk stratification of ventricular arrhythmias in systolic heart failure has evolved, with an increasing role for cardiac magnetic resonance imaging to identify underlying substrate and scar burden. Medical therapy for heart failure has greatly improved, and the role of primary prevention defibrillators in nonischemic cardiomyopathy has become more ambiguous. Catheter ablation is superior to medical therapy for arrhythmia control and should be considered early, particularly for premature ventricular complex mediated cardiomyopathy. Novel technologies to deliver energy to previously inaccessible sites include high-impedance catheter irrigants, multicatheter bipolar ablation, specialized catheters with extendable needles, transcoronary ethanol infusion, and stereotactic body radiation therapy. SUMMARY: Assessment and management of ventricular arrhythmias in systolic heart failure requires a systematic, multimodality approach aimed at identifying the underlying cause and reversible causes, optimizing medical therapy, assessing need for an implantable cardioverter defibrillator, and considering catheter ablation. Further research will focus on prevention of disease progression, improved risk stratification, and ablation technologies that minimize procedure duration and enable delivery of durable lesions.