Endocardial Scar-Homogenization With vs Without Epicardial Ablation in VT Patients With Ischemic Cardiomyopathy

Sanghamitra Mohanty, Chintan Trivedi, Luigi Di Biase, John D. Burkhardt, Domenico Giovanni Della Rocca, Carola Gianni, Bryan MacDonald, Angel Mayedo, Sai Shishir Shetty, Will Zagrodzky, Faiz Baqai, Mohamed Bassiouny, G. Joseph Gallinghouse, Rodney Horton, Amin Al-Ahmad, Andrea Natale

Research output: Contribution to journalArticlepeer-review

1 Scopus citations

Abstract

Objectives: In this study, the authors investigated the ablation success of scar homogenization with combined (epicardial + endocardial) vs endocardial-only approach for ventricular tachycardia (VT) in patients with ischemic cardiomyopathy (ICM) at 5 years of follow-up. Background: Best ablation approach to achieve long-term success rate in VT patients with ICM is not known yet. Methods: Consecutive ICM patients undergoing VT ablation at our center were classified into group 1: endocardial + epicardial scar homogenization and group 2: endocardial scar homogenization. Patients with previous open heart surgery were excluded. Epicardial ablation was performed despite being noninducible after endocardial ablation in all group 1 patients. All patients underwent bipolar substrate mapping with standard scar settings defined as normal tissue >1.5 mV and severe scar <0.5 mV. Noninducibility of monomorphic VT was the procedural endpoint in both groups. Patients were followed up every 4 months for 5 years with implantable device interrogations. Results: A total of 361 patients (group 1: n = 70 and group 2: n = 291) were included in the study. At 5 years, 81.4% (n = 57/70) patients from group 1 and 66.3% (n = 193/291) from group 2 were arrhythmia-free (P = 0.01) Of those patients, 26 of 57 (45.6%) and 172 of 193 (89.1%) from group 1 and group 2 respectively were on anti-arrhythmic drugs (AAD) (log-rank P < 0.001). After adjusting for age, sex, and obstructive sleep apnea, endo-epicardial scar homogenization was associated with a significant reduction in arrhythmia-recurrence (HR: 0.48; 95% CI: 0.27-0.86; P = 0.02). Conclusions: In this series of patients with ICM and VT, epicardial substrate was detected in all group 1 patients despite being noninducible after endocardial ablation. Moreover, combined endo-epicardial scar homogenization was associated with a significantly higher success rate at 5 years of follow-up and a substantially lower need for antiarrhythmic drugs after the procedure compared with the endocardial ablation alone.

Original languageEnglish (US)
Pages (from-to)453-461
Number of pages9
JournalJACC: Clinical Electrophysiology
Volume8
Issue number4
DOIs
StatePublished - Apr 2022

Keywords

  • endocardial ablation
  • epicardial ablation
  • ischemic cardiomyopathy
  • ventricular tachycardia

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

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