Endo‐epicardial ablation vs endocardial ablation for the management of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy: A systematic review and meta‐analysis

Abstract

BackgroundThe pathologic process of ARVC (arrhythmogenic right ventricular cardiomyopathy) typically originates in the epicardium or subepicardial layers with progression toward endocardium. However, in the most recent ARVC international task force consensus statement, epicardial ventricular tachycardia (VT) ablation is recommended as a Class I indication only in patients with at least one failed endocardial VT ablation attempt.ObjectiveThe aim of this meta‐analysis is to assess the outcomes of ARVC patients undergoing combined endo‐epicardial VT ablation, as compared to endocardial ablation alone.MethodsA systematic review of PubMed, Embase, and Cochrane was performed for studies reporting clinical outcomes of endo‐epicardial VT ablation vs endocardial‐only VT ablation in patients with ARVC. Fixed‐Effect model was used if I2 < 25 and the Random‐Effects Model was used if I2 ≥ 25%.ResultsNine studies consisting of 452 patients were included (mean age 42.3 ± 5.7 years; 70% male). After a mean follow‐up of 48.1 ± 21.5 months, endo‐epicardial ablation was associated with 42% relative risk reduction in VA recurrence as opposed to endocardial ablation alone (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.45‐0.75; P < .0001). No significant differences were noted between endo‐epicardial and endocardial VT ablation groups in terms of all‐cause mortality (RR, 1.19; 95% CI, 0.03‐47.08; P = .93) and acute procedural complications (RR, 5.39; 95% CI, 0.60‐48.74; P = .13).ConclusionsOur findings suggest that in patients with ARVC, endo‐epicardial VT ablation is associated with a significant reduction in VA recurrence as opposed to endocardial ablation alone, without a significant difference in all‐cause mortality or acute procedural complications.

Antiarrhythmic Drug Therapy in Arrhythmogenic Right Ventricular Cardiomyopathy

“…It is recommended in patients with recurrent VT or ICD interventions despite a trial of antiarrhythmic therapy. Generally, a combined endocardial/epicardial approach should be considered, particularly if an endocardial approach has failed [ 19 ]. However, it is important to note that ablation is not curative and due to the progressive nature of the disease, recurrence rates of VT following endocardial ablation are reported to be up to 50–75% over 3 years [ 3 , 20 ].…”

Predictors of long-term ventricular tachyarrhythmia recurrence after combined endo-epicardial ablation in patients with structural heart disease

“…Так, например, частота рецидивов после аблации субстрата постинфарктной и неишемической ЖТ сопоставима в остром периоде, но значительно отличается спустя 1 год -57% против 40,7% соответственно [12]. Преимущество комбинированной эндо-эпикардиальной аблации при неишемической кардиомиопатии в сравнении с изолированной эндокардиальной аблацией показано в ряде исследований, однако эффективность аблации все же далека от идеальной и составляет от 59 до 85% [4,13,14].…”

“…В таком случае проводится картирование и аблация субстрата тахикардии со стороны эпикардиальной поверхности. Эпикардиальный доступ актуален у пациентов с аритмогенной кардиомиопатией правого желудочка (АКПЖ) [4][5][6], при постмиокардитическом кардиосклерозе, постинфарктных рубцах [7]. Тем не менее, несмотря на комбинированную, эндо-эпикардиальную модификацию субстрата ЖТ, рецидивы ЖТ встречаются нередко.…”