Is programmed electrical stimulation mandatory for recognition of ventricular arrhythmogenicity in heart failure?

Ischemic cardiomyopathy often presents with advanced heart failure necessitating an intensive multidisciplinary approach to management. These patients constitute a very difficult population presenting with angina and ventricular tachyarrhythmias sometimes presenting as sudden cardiac death. In those patients presenting with spontaneous ventricular tachyarrhythmias, treatment with automated intracardiac defibrillator implantation has a significant mortality benefit. In patients with significant left ventricular (LV) dilatation and a left ventricular ejection fraction <= 30%, guidelines state that device implantation should be preceded by programmed electrical stimulation, which demonstrates inducible ventricular tachyarrhythmia. The treatment options for patients with moderate LV dilatation and ejection fraction >= 30% is individualized. Devices have their associated problems. Radiofrequency ablation has mixed results. Surgical cryoablation when performed concomitantly with surgical ventricular restoration has shown promising results. But, this option remains isolated to patients eligible for surgical ventricular restoration. Programmed electrical stimulation for inducibility of ventricular tachyarrhythmias in these patients also has a questionable role. The need for programmed electrical stimulation prior to cryoablation also seems highly individualized. In this review, we discuss the mechanisms of ischemic ventricular tachyarrhythmias and treatment options in heart failure. The mechanisms of ventricular arrhythmogenesis in ischemic cardiomyopathy help in formulating novel technical modifications for cryoablation when performed concomitantly with surgical ventricular restoration.