Catheter Ablation of Ventricular Tachycardia in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: A Sequential Approach

Abstract

Background It has been suggested that endocardial and epicardial ablation of ventricular tachycardia ( VT ) improves outcome in arrhythmogenic right ventricular cardiomyopathy/dysplasia. We investigated our sequential approach for VT ablation in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia in a single center. Methods and Results We included 47 patients (44±16 years) with definite (81%) or borderline (19%) arrhythmogenic right ventricular cardiomyopathy/dysplasia between 1998 and 2016. Our ablation strategy was to target the endocardial substrate. Epicardial ablation was performed in case of acute ablation failure or lack of an endocardial substrate. Single and multiple procedural 1‐ and 5‐year outcome data for the first occurrence of the study end points (sustained VT /ventricular fibrillation, heart transplant, and death after the index procedure, and sustained VT /ventricular fibrillation for multiple procedures) are reported. Eighty‐one radiofrequency ablation procedures were performed (mean 1.7 per patient, range 1–4). Forty‐five (56%) ablation procedures were performed via an endocardial, 11 (13%) via an epicardial, and 25 (31%) via a combined endo‐ and epicardial approach. Complete acute success was achieved in 65 (80%) procedures, and partial success in 13 (16%). After a median follow‐up of 50.8 (interquartile range, [18.6; 99.2]) months after the index procedure, 17 (36%) patients were free from the primary end point. After multiple procedures, freedom from sustained VT /ventricular fibrillation was 63% (95% CI , 52–75) at 1 year, and 45% (95% CI , 34–61) at 5 years, with 36% of patients receiving only endocardial radiofrequency ablation. A trend (log rank P =0.058) towards an improved outcome using a combined endo‐/epicardial approach was observed after multiple procedures. Conclusion Endocardial ablation can be effective in a considerable number of arrhythmogenic right ventricular cardiomyopathy/dysplasia patients with VT , potentially obviating the need for an epicardial approach.

Incidence, Predictors, and Success of Ventricular Tachycardia Catheter Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy (from the Nordic ARVC Registry)

“…Prior studies of patients undergoing VT ablation have shown a large variability in reported outcomes. [3][4][5][6][7][8][9][10][11][12] In general the most promising results have been demonstrated in from highvolume single-centers using an epicardial ablation strategy, which has been increasingly utilized throughout the last decade. 4,5,7,10 These studies have reported VT-free survivals ranging from 91% after a median follow up of 11 months to 71% after 56 months.…”

“…Moreover, several studies have reported varying results on the procedural efficacy. [3][4][5][6][7][8][9][10][11][12] These studies have predominantly been conducted at large referral centers specialized in VT ablation and therefore the results may not reflect the general effect of VT ablation due to the selection and high volume in these centers. Therefore, the purpose of this study was to evaluate predictors and use of VT ablation and the post-procedural long-term outcome in a large multicenter cohort of patients with ARVC.…”

Epicardial access for VT ablation: analysis of two different puncture techniques, incidence of adhesions and complication management

“…If ECG criteria anticipated left ventricular access, retrograde transaortic and/or antegrade transseptal puncture was performed after epicardial puncture to avoid access under heparinization. Electrophysiological study, mapping and ablation were performed as described by our group previously [ 17 ].…”

“…Pericardial access was performed as previously described [ 17 ]. Until February 2012 the largest part of epicardial ablation procedures were regularly performed fluoroscopically guided in AP view with a 14-gauge cannula (Angiocath, Becton Dickinson, Sandy, UT, USA) in an inferior and left medioclavicular oriented direction, between the left border of the subxiphoid and the rib cage, the so-called Larrey’s gap (Figs.…”

Endocardial ablation can abolish epicardial LAVAs in arrhythmogenic cardiomyopathy: A case report

“…In concordance with the findings in this report, a recent publication showed no significant difference in clinical outcome between an endocardial and endocardial-epicardial approach in patients with ARVC, with a substantial proportion of patients receiving only endocardial ablation, not needing further epicardial ablation. 8…”