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

A Systematic Review and Meta-Analysis

Jorge E. Romero, Roberto C. Cerrud-Rodriguez, Luigi Di Biase, Juan Carlos Diaz, Isabella Alviz, Vito Grupposo, Luis Cerna, Ricardo Avendano, Usha Tedrow, Andrea Natale, Roderick Tung, Saurabh Kumar

Research output: Contribution to journalArticle

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Abstract

Objectives: This study sought to determine whether combined endocardial-epicardial (endo-epi) ablation was superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT). Background: Limited single-center studies suggest that combined endo-epi ablation strategy may be superior to endocardial ablation (endo) alone in patients with nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), and ischemic cardiomyopathy (ICM). Methods: A systematic review of Medline, Cochrane, and Embase databases was performed for studies that reported outcomes comparing endo-epi with endo VT ablation alone. Results: Seventeen studies consisting of 975 patients were included (mean 56 ± 10 years of age; 79% male; NICM in 36.6%; ICM in 32.8%; and ARVC in 30.6%). After a mean follow-up of 27 ± 21 months, endo-epi ablation was associated with a 35% reduction in risk of VT recurrence compared with endocardial ablation alone (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.55 to 0.78; p < 0.001). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR: 0.43; 95% CI: 0.28 to 0.67; p = 0.0002) and ARVC (RR: 0.59; 95% CI: 0.43 to 0.82; p = 0.0002), with a nonsignificant trend in NICM (RR: 0.87; 95% CI: 0.70 to 1.08; p = 0.20). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR: 0.56; 95% CI: 0.32 to 0.97; p = 0.04). Acute procedural complications were higher with the endo-epi approach (RR: 2.62; 95% CI: 0.91 to 7.52; p = 0.07). Conclusions: This meta-analysis suggests that a combined endo-epi ablation is associated with a lower risk of VT recurrence and subsequent mortality than endo only VT ablation in patients with scar-related VT. Procedural complications, however, are higher with the endo-epi approach.

Original languageEnglish (US)
Pages (from-to)13-24
Number of pages12
JournalJACC: Clinical Electrophysiology
Volume5
Issue number1
DOIs
StatePublished - Jan 1 2019

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Catheter Ablation
Ventricular Tachycardia
Meta-Analysis
Cardiomyopathies
Heart Diseases
Odds Ratio
Confidence Intervals
Arrhythmogenic Right Ventricular Dysplasia
Recurrence
Cicatrix
Mortality
Risk Reduction Behavior
Outcome Assessment (Health Care)
Databases

Keywords

  • arrhythmogenic right ventricular cardiomyopathy
  • catheter ablation
  • endocardial ablation
  • epicardial ablation
  • ischemic cardiomyopathy
  • nonischemic cardiomyopathy
  • structural heart disease
  • ventricular tachycardia
  • VT recurrence

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease : A Systematic Review and Meta-Analysis. / Romero, Jorge E.; Cerrud-Rodriguez, Roberto C.; Di Biase, Luigi; Diaz, Juan Carlos; Alviz, Isabella; Grupposo, Vito; Cerna, Luis; Avendano, Ricardo; Tedrow, Usha; Natale, Andrea; Tung, Roderick; Kumar, Saurabh.

In: JACC: Clinical Electrophysiology, Vol. 5, No. 1, 01.01.2019, p. 13-24.

Research output: Contribution to journalArticle

Romero, Jorge E. ; Cerrud-Rodriguez, Roberto C. ; Di Biase, Luigi ; Diaz, Juan Carlos ; Alviz, Isabella ; Grupposo, Vito ; Cerna, Luis ; Avendano, Ricardo ; Tedrow, Usha ; Natale, Andrea ; Tung, Roderick ; Kumar, Saurabh. / Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease : A Systematic Review and Meta-Analysis. In: JACC: Clinical Electrophysiology. 2019 ; Vol. 5, No. 1. pp. 13-24.
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abstract = "Objectives: This study sought to determine whether combined endocardial-epicardial (endo-epi) ablation was superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT). Background: Limited single-center studies suggest that combined endo-epi ablation strategy may be superior to endocardial ablation (endo) alone in patients with nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), and ischemic cardiomyopathy (ICM). Methods: A systematic review of Medline, Cochrane, and Embase databases was performed for studies that reported outcomes comparing endo-epi with endo VT ablation alone. Results: Seventeen studies consisting of 975 patients were included (mean 56 ± 10 years of age; 79{\%} male; NICM in 36.6{\%}; ICM in 32.8{\%}; and ARVC in 30.6{\%}). After a mean follow-up of 27 ± 21 months, endo-epi ablation was associated with a 35{\%} reduction in risk of VT recurrence compared with endocardial ablation alone (risk ratio [RR]: 0.65; 95{\%} confidence interval [CI]: 0.55 to 0.78; p < 0.001). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR: 0.43; 95{\%} CI: 0.28 to 0.67; p = 0.0002) and ARVC (RR: 0.59; 95{\%} CI: 0.43 to 0.82; p = 0.0002), with a nonsignificant trend in NICM (RR: 0.87; 95{\%} CI: 0.70 to 1.08; p = 0.20). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR: 0.56; 95{\%} CI: 0.32 to 0.97; p = 0.04). Acute procedural complications were higher with the endo-epi approach (RR: 2.62; 95{\%} CI: 0.91 to 7.52; p = 0.07). Conclusions: This meta-analysis suggests that a combined endo-epi ablation is associated with a lower risk of VT recurrence and subsequent mortality than endo only VT ablation in patients with scar-related VT. Procedural complications, however, are higher with the endo-epi approach.",
keywords = "arrhythmogenic right ventricular cardiomyopathy, catheter ablation, endocardial ablation, epicardial ablation, ischemic cardiomyopathy, nonischemic cardiomyopathy, structural heart disease, ventricular tachycardia, VT recurrence",
author = "Romero, {Jorge E.} and Cerrud-Rodriguez, {Roberto C.} and {Di Biase}, Luigi and Diaz, {Juan Carlos} and Isabella Alviz and Vito Grupposo and Luis Cerna and Ricardo Avendano and Usha Tedrow and Andrea Natale and Roderick Tung and Saurabh Kumar",
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T1 - Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease

T2 - A Systematic Review and Meta-Analysis

AU - Romero, Jorge E.

AU - Cerrud-Rodriguez, Roberto C.

AU - Di Biase, Luigi

AU - Diaz, Juan Carlos

AU - Alviz, Isabella

AU - Grupposo, Vito

AU - Cerna, Luis

AU - Avendano, Ricardo

AU - Tedrow, Usha

AU - Natale, Andrea

AU - Tung, Roderick

AU - Kumar, Saurabh

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Objectives: This study sought to determine whether combined endocardial-epicardial (endo-epi) ablation was superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT). Background: Limited single-center studies suggest that combined endo-epi ablation strategy may be superior to endocardial ablation (endo) alone in patients with nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), and ischemic cardiomyopathy (ICM). Methods: A systematic review of Medline, Cochrane, and Embase databases was performed for studies that reported outcomes comparing endo-epi with endo VT ablation alone. Results: Seventeen studies consisting of 975 patients were included (mean 56 ± 10 years of age; 79% male; NICM in 36.6%; ICM in 32.8%; and ARVC in 30.6%). After a mean follow-up of 27 ± 21 months, endo-epi ablation was associated with a 35% reduction in risk of VT recurrence compared with endocardial ablation alone (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.55 to 0.78; p < 0.001). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR: 0.43; 95% CI: 0.28 to 0.67; p = 0.0002) and ARVC (RR: 0.59; 95% CI: 0.43 to 0.82; p = 0.0002), with a nonsignificant trend in NICM (RR: 0.87; 95% CI: 0.70 to 1.08; p = 0.20). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR: 0.56; 95% CI: 0.32 to 0.97; p = 0.04). Acute procedural complications were higher with the endo-epi approach (RR: 2.62; 95% CI: 0.91 to 7.52; p = 0.07). Conclusions: This meta-analysis suggests that a combined endo-epi ablation is associated with a lower risk of VT recurrence and subsequent mortality than endo only VT ablation in patients with scar-related VT. Procedural complications, however, are higher with the endo-epi approach.

AB - Objectives: This study sought to determine whether combined endocardial-epicardial (endo-epi) ablation was superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT). Background: Limited single-center studies suggest that combined endo-epi ablation strategy may be superior to endocardial ablation (endo) alone in patients with nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), and ischemic cardiomyopathy (ICM). Methods: A systematic review of Medline, Cochrane, and Embase databases was performed for studies that reported outcomes comparing endo-epi with endo VT ablation alone. Results: Seventeen studies consisting of 975 patients were included (mean 56 ± 10 years of age; 79% male; NICM in 36.6%; ICM in 32.8%; and ARVC in 30.6%). After a mean follow-up of 27 ± 21 months, endo-epi ablation was associated with a 35% reduction in risk of VT recurrence compared with endocardial ablation alone (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.55 to 0.78; p < 0.001). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR: 0.43; 95% CI: 0.28 to 0.67; p = 0.0002) and ARVC (RR: 0.59; 95% CI: 0.43 to 0.82; p = 0.0002), with a nonsignificant trend in NICM (RR: 0.87; 95% CI: 0.70 to 1.08; p = 0.20). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR: 0.56; 95% CI: 0.32 to 0.97; p = 0.04). Acute procedural complications were higher with the endo-epi approach (RR: 2.62; 95% CI: 0.91 to 7.52; p = 0.07). Conclusions: This meta-analysis suggests that a combined endo-epi ablation is associated with a lower risk of VT recurrence and subsequent mortality than endo only VT ablation in patients with scar-related VT. Procedural complications, however, are higher with the endo-epi approach.

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KW - catheter ablation

KW - endocardial ablation

KW - epicardial ablation

KW - ischemic cardiomyopathy

KW - nonischemic cardiomyopathy

KW - structural heart disease

KW - ventricular tachycardia

KW - VT recurrence

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