Ablation of Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Arrhythmia-Free Survival After Endo-Epicardial Substrate Based Mapping and Ablation

Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, TX, USA.
Circulation Arrhythmia and Electrophysiology (Impact Factor: 4.51). 06/2011; 4(4):478-85. DOI: 10.1161/CIRCEP.111.963066
Source: PubMed


In patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy, freedom from ventricular arrhythmias (VAs) after endocardial ablation is limited. We compared the long-term freedom from recurrent VAs by using endocardial-alone ablation versus endo-epicardial substrate-based ablation.
Forty-nine patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergoing ablation of ventricular tachycardia (VT) were divided into 2 groups: endocardial-alone ablation (group 1, n = 23) and endo-epicardial ablation (group 2, n = 26). All patients had an implantable cardioverter-defibrillator (ICD). Conventional and 3D mappings were used to determine the mechanism of induced VTs and to identify area of "scar" or "abnormal" myocardium. All critical sites responsible for VTs and points with "abnormal" potential were targeted for ablation from endocardium (group 1) or from both endocardium and epicardium (group 2). The procedural end point was noninducibility of sustained, monomorphic VT with isoproterenol. The presence of frequent premature ventricular contractions at the end of ablation was recorded. Patients were followed up by ECG, Holter, and ICD interrogation. After a follow-up of at least 3 years, freedom from VAs or ICD therapy was 52.2% (12/23) in group 1 and 84.6% (22/26) in group 2 (P = 0.029), with 21.7% (5/23) and 69.2% (18/26) patients off antiarrhythmic drugs (P < 0.001), respectively. Compared with patients with no premature ventricular contractions after ablation, patients with frequent premature ventricular contractions after ablation were more likely to have VA recurrence/ICD therapy [3/33 (9%) versus 12/16 (75%); log-rank P<0.001].
An endo-epicardial-based ablation strategy achieves higher long-term freedom from recurrent VAs off antiarrhythmic therapy in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy when compared with endocardial-alone ablation. The presence of ≥ 10 premature ventricular contractions per minute after ablation is associated with more VA recurrence.

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    • "Accordingly, in a recent study by Philips et al. [69] the overall freedom from VT of 175 ablation procedures in 87 AC patients was 47 %, 21 %, and 15 %, at 1, 5, and 10 years, respectively, over a mean follow-up of 88.3 ± 66 months. The outcomes of VT ablation are improved with a combined endocardial and epicardial approach, incorporating a substrate-based strategy [69, 70]. "
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    ABSTRACT: Arrhythmogenic cardiomyopathy (AC), also known as arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), is a hereditary disease characterised by ventricular arrhythmias, right ventricular and/or left ventricular dysfunction, and fibrofatty replacement of cardiomyocytes. Patients with AC typically present between the second and the fourth decade of life with ventricular tachycardias. However, sudden cardiac death (SCD) may be the first manifestation, often at young age in the concealed stage of disease. AC is diagnosed by a set of clinically applicable criteria defined by an international Task Force. The current Task Force Criteria are the essential standard for a correct diagnosis in individuals suspected of AC. The genetic substrate for AC is predominantly identified in genes encoding desmosomal proteins. In a minority of patients a non-desmosomal mutation predisposes to the phenotype. Risk stratification in AC is imperfect at present. Genotype-phenotype correlation analysis may provide more insight into risk profiles of index patients and family members. In addition to symptomatic treatment, prevention of SCD is the most important therapeutic goal in AC. Therapeutic options in symptomatic patients include antiarrhythmic drugs, catheter ablation, and ICD implantation. Furthermore, patients with AC and also all pathogenic mutation carriers should be advised against practising competitive and endurance sports.
    Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 05/2014; 22(7-8). DOI:10.1007/s12471-014-0563-7 · 1.84 Impact Factor
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    • "Interestingly enough the right basal wall evaluated with the electro-anatomical maps resulted thicker in ARVD patients ( > 10 mm) as compared to the reference patients without structural heart disease (5-10 mm) and to this end we have to remember that irrigated RF energy delivery in the endocardial surface is unable to produce transmural lesions. Another paper that strengthens the importance of an endo-epicardial approach in this type of cardiomyopathy has been published by Bai et al [41]. Forty-nine patients with ARVD divided into two groups underwent endocardial ablation alone (group 1) or endo-epicardial ablation (group 2). "
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    ABSTRACT: Epicardial ablation has lately become a necessary tool to approach some ventricular tachycardias in different types of cardiomyopathy. Its diffusion is now limited to a few high volume centers not because of the difficulty of the pericardial puncture but since it requires high competence not only in the VT ablation field but also in knowing and recognizing the possible complications each of which require a careful treatment. This article will review the state of the art of epicardial ablation with special attention to the procedural aspects and to the possible selection criteria of the patients
    Indian pacing and electrophysiology journal 11/2012; 12(6):250-68.
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    ABSTRACT: Islets of myocytes within fibrofatty scars represent the substrate for reentrant ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy (ARVC). Electroanatomic mapping can reliably identify such areas. To prospectively test the association between late and fragmented electrograms within scar and arrhythmic events in patients with ARVC. High-density right ventricle electroanatomic mapping was performed in 32 patients with ARVC without history of cardiac arrest or sustained ventricular arrhythmias. Standard definitions of electroanatomic scars and fragmented, isolated, and very late potentials were used. All patients received an implantable cardioverter-defibrillator for the primary prevention of sudden death. After a mean follow-up of 25 ± 7 months, 12 (38%) patients received appropriate implantable cardioverter-defibrillator shock for sustained ventricular arrhythmias. With the exception of a higher rate of previous syncope (P = .053), patients with arrhythmic events at follow-up did not differ from those who remained free from arrhythmic events in terms of other clinical variables, including cardiac magnetic resonance findings. Electroanatomic scars were present in all patients. The distribution and extent of electroanatomic scars were similar in the 2 groups (38 ± 25 cm(2) vs 33 ± 20 cm(2); P = .51). However, patients with implantable cardioverter-defibrillator shock had a higher prevalence of fragmented electrograms (92% vs 20%; P <.001), of isolated late potentials (75% vs 20%; P = .004), and of very late potentials (67% vs 25%; P = .030). Fragmented electrograms were the only variable independently associated with arrhythmic events at follow-up (hazard ratio 21; P = .015). The presence of fragmented and delayed electrograms within the scar predicts arrhythmic events in ARVC.
    Heart rhythm: the official journal of the Heart Rhythm Society 03/2012; 9(8):1200-6. DOI:10.1016/j.hrthm.2012.03.057 · 5.08 Impact Factor
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