Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease

Romero, Jorge; Cerrud‐Rodriguez, Roberto; Biase, Luigi Di; Díaz, Juan Carlos; Grupposo, Vito; Cerna, Luis; Avendaño, Ricardo; Tedrow, Usha B.; Natale, Andrea; Tung, Roderick; Kumar, Saurabh

doi:10.1016/j.jacep.2018.08.010

Cited by 63 publications

(42 citation statements)

References 35 publications

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“…Overall, our results are consistent with a recently published meta‐analysis by Romero et al. Their study was published during the conduction of our systematic review and meta‐analysis, and the consistent results attest to the robust methods on both studies.…”

Section: Discussionsupporting

confidence: 92%

Endo‐epicardial vs endocardial‐only catheter ablation of ventricular tachycardia: A meta‐analysis

Cardoso

Assis

d’Ávila³

2019

Cardiovasc electrophysiol

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Introduction The efficacy of endocardial catheter ablation for ventricular tachycardia (VT) can be limited by intramural or epicardial substrates. Adding epicardial mapping and ablation may improve arrhythmia outcomes compared with an endocardial‐only approach. Methods We performed a systematic review and meta‐analysis of studies comparing a strategy of endo‐epicardial catheter ablation to an endocardial‐only approach for VT. Subanalyses were performed for ischemic and nonischemic cardiomyopathies. Results A total of 22 studies including 1138 patients were included in the meta‐analysis. Of those, 44% underwent an endo‐epicardial approach. During intermediate to long‐term follow‐up (average 7 to 70 months), recurrent VT or appropriate implantable cardioverter defibrillator (ICD) therapies were significantly lower with the endo‐epicardial strategy (OR, 0.52; P < .01). All‐cause mortality was also lower in this group (OR, 0.50; P = .03). No difference between endo‐epicardial and endocardial‐only ablation was noted in nonischemic cardiomyopathies. Among 323 patients with ischemic cardiomyopathy, recurrent VT or appropriate ICD therapies was less frequent in the endo‐epicardial group (OR, 0.39; P = .01), as was all‐cause mortality (OR, 0.38; P = .05). In patients with arrhythmogenic right ventricular cardiomyopathy, recurrent VT or appropriate ICD therapy was also lower in the endo‐epicardial group (OR, 0.42; P = .04). Conclusion These results suggest that a strategy of combined endo‐ and epicardial access for mapping and ablation of VT may provide superior efficacy to an endocardial‐only approach in selected patients. Randomized trials are warranted to further investigate this question.

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Section: Discussionsupporting

confidence: 92%

Endo‐epicardial vs endocardial‐only catheter ablation of ventricular tachycardia: A meta‐analysis

Cardoso

Assis

d’Ávila³

2019

Cardiovasc electrophysiol

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“…Practically, epicardial mapping and ablation would be best performed using standard percutaneous techniques prior to LVAD implant, or concurrent with the implant procedure itself. It is increasingly recognized that many patients with ischemic cardiomyopathy have both endocardial and epicardial substrate contributing to the three‐dimensional VA circuit, and a strategy that includes epicardial ablation has been associated with improved freedom from VA in these patients as well …”

Section: Discussionmentioning

confidence: 99%

Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation

Moss

Oesterle

Raiman

et al. 2018

Cardiovasc electrophysiol

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Introduction: Ventricular arrhythmias (VA) after left ventricular assist device (LVAD) placement are associated with increased morbidity and mortality.We sought to assess epicardial voltage characteristics at the time of LVAD implantation and investigate relationships between scar burden and postimplant VA. Methods and Results: Consecutive patients underwent open chest epicardial electroanatomic mapping immediately before LVAD implantation. Areas of low voltage and sites with local abnormal potentials were identified. Patients were followed prospectively for postimplant VA and clinical outcomes. Between 2015 and 2017, 36 patients underwent high-density intraoperative epicardial voltage mapping; 15 had complete maps suitable for analysis. Mapping required a median of 11.8 (interquartile range [IQR], 8.5-12.7) minutes, with a median of 2650 (IQR, 2139-3191) points sampled per patient. Over a median follow-up of 311 (IQR, 168-469) postoperative days, four patients (27%) experienced sustained VA. Patients with postimplant VA were more likely to have had preimplant implantable cardioverter defibrillator shocks (100% vs 27%; P = 0.03), ventriculartachycardia storm (75% vs 9%; P = 0.03), and lower ejection fraction (13.5 vs 19.0%, P = 0.05). Patients with postimplant VA also had a significantly higher burden of epicardial low bipolar voltage points: 55.4% vs 24.9% of points were less than 0.5 mV (P = 0.01), and 88.9% vs 63.7% of points less than 1.5 mV (P = 0.004).Conclusions: Intraoperative high-density epicardial mapping during LVAD implantation is safe and efficient, facilitating characterization of a potentially arrhythmogenic substrate. An increased burden of the epicardial scar may be associated with a higher incidence of postimplant VA. The role of empiric

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“…17 Several recent studies have demonstrated the superiority of combined endoepicardial access to improve success rates of the procedure in ARVC/D. 18 Combined endo-epicardial access at first step is now the routine approach in our daily practice. This strategy is supported by the 2015 expert consensus statement that proposed "a combined endocardial/epicardial VT ablation approach as an initial ablation strategy, provided that the operator and electrophysiologic laboratory are experienced performing epicardial VT ablation in patients with ARVC/D" (class IIa recommendation).…”

Section: Test Your Knowledge!mentioning

confidence: 99%

Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease

Cited by 63 publications

References 35 publications

Endo‐epicardial vs endocardial‐only catheter ablation of ventricular tachycardia: A meta‐analysis

Endo‐epicardial vs endocardial‐only catheter ablation of ventricular tachycardia: A meta‐analysis

Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation

My approach to ventricular tachycardia ablation in patient with arrhythmogenic right ventricular cardiomyopathy/dysplasia

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