Endo-Epicardial vs. Endocardial Only VT Ablation

Oct 22, 2018
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Authors:
Romero J, Cerrud-Rodriguez RC, Di Biase L, et al.
Citation:
Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2018;Sep 26:[Epub ahead of print].
Summary By:
Thomas C. Crawford, MD, FACC

Study Questions:

Is combined endocardial-epicardial (endo-epi) ablation superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT)?

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 (nonischemic cardiomyopathy [NICM] in 36.6%, ischemic cardiomyopathy [ICM] in 32.8%, and arrhythmogenic right ventricular dysplasia [ARVC] in 30.6%). After a mean follow-up of 27 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], 0.55-0.78). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR, 0.43; 95% CI, 0.28-0.67) and ARVC (RR, 0.59; 95% CI, 0.43-0.82), with a nonsignificant trend in NICM (RR, 0.87; 95% CI, 0.70-1.08). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR, 0.56; 95% CI, 0.32-0.97). Acute procedural complications were higher with the endo-epi approach (RR, 2.62; 95% CI, 0.91-7.52).

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 are higher with the endo-epi approach.

Perspective:

One of the most common reasons behind failure of VT ablation is inability to affect the arrhythmogenic substrate with the currently available ablation technology. This is particularly an issue for disease processes preferentially affecting the mid myocardium or epicardium. The meta-analysis suggests that epicardial mapping and ablation may be associated with improved outcomes, including mortality. Morphological criteria on 12-lead electrocardiography, specific myocardial substrates, or the location of late gadolinium contrast on cardiac magnetic resonance imaging may be used to decide whether to access the epicardium. Further studies are needed to help define the population most likely to benefit.

Keywords: Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Cardiomyopathies, Catheter Ablation, Cicatrix, Endocardium, Epicardial Mapping, Heart Failure, Myocardium, Pericardium, Secondary Prevention, Tachycardia, Ventricular


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