Outcomes of VT Ablation in Nonischemic Heart Disease by Etiology

Study Questions:

What are the outcomes of ventricular tachycardia (VT) ablation across various etiologies of nonischemic cardiomyopathy (NICM)?

Methods:

Outcomes data from 12 international centers were analyzed. Patient characteristics and outcomes were noted for the six most common NICM etiologies. Multivariable Cox proportional hazard model was used to adjust for potential confounders.

Results:

There were 780 patients (average age 57 years, 18% female, left ventricular ejection fraction 37% ± 13%). Etiologies were as follows: dilated idiopathic cardiomyopathy (DCM) 66%, arrhythmogenic right ventricular cardiomyopathy (ARVC) 13%, valvular cardiomyopathy 6%, myocarditis 6%, hypertrophic cardiomyopathy (HCM) 4%, and sarcoidosis 3%. One-year freedom from VT was 69%; and freedom from VT, heart transplantation, and death was 62%. On unadjusted competing risk analysis, VT ablation in ARVC demonstrated superior VT-free survival (82%) vs. DCM (p ≤ 0.01). Valvular cardiomyopathy had the poorest unadjusted VT-free survival at 47% (p < 0.01). After adjusting for comorbidities, myocarditis, ARVC, and DCM demonstrated similar outcomes, while HCM, valvular cardiomyopathy, and sarcoidosis had the highest risk of VT recurrence.

Conclusions:

Catheter ablation of VT in NICM is effective. Outcomes with ARVC, myocarditis, and DCM are superior to outcomes of patients with HCM, valvular cardiomyopathy, and sarcoidosis.

Perspective:

Occurrence of VT in structural heart disease is determined by the underlying substrate. Ablation outcomes are better for ischemic substrates, where it is more common to encounter dense replacement fibrosis rather than diffuse reticular fibrosis. Additionally, the substrate for sarcoidosis, valvular cardiomyopathy, and HCM is usually not as accessible (i.e., more often septal, mid-myocardial, and epicardial). Unfortunately, the location of the scar, as observed on imaging and electroanatomic data, is not presented. This report highlights the need for methods to better characterize the substrate in NICMs.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Transplant, Interventions and Structural Heart Disease

Keywords: Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Cardiomyopathies, Cardiomyopathy, Hypertrophic, Catheter Ablation, Cicatrix, Heart Failure, Heart Transplantation, Heart Valve Diseases, Myocarditis, Outcome Assessment (Health Care), Sarcoidosis, Stroke Volume, Tachycardia, Ventricular


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