Infarct transmurality as a criterion for first-line endo-epicardial substrate–guided ventricular tachycardia ablation in ischemic cardiomyopathy

• Published in: Heart rhythm Vol. 13; no. 1; pp. 85 - 95
• Main Authors: Acosta, Juan, MD, Fernández-Armenta, Juan, MD, Penela, Diego, MD, Andreu, David, MSc, PhD, Borras, Roger, MSc, Vassanelli, Francesca, MD, Korshunov, Viatcheslav, MD, Perea, Rosario J., MD, PhD, de Caralt, Teresa M., MD, PhD, Ortiz, Jose T., MD, PhD, Fita, Guillermina, MD, PhD, Sitges, Marta, MD, PhD, Brugada, Josep, MD, PhD, Mont, Lluis, MD, PhD, Berruezo, Antonio, MD, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.01.2016
• Subjects: Aged; Cardiovascular; Catheter Ablation - adverse effects; Catheter Ablation - methods; Endocardium - physiopathology; Endocardium - surgery; Epicardial approach; Epicardial Mapping - methods; Female; Follow-Up Studies; Humans; Infarct transmurality; Male; Middle Aged; Myocardial Infarction - complications; Proportional Hazards Models; Recurrence; Tachycardia, Ventricular - diagnosis; Tachycardia, Ventricular - etiology; Tachycardia, Ventricular - surgery; Treatment Outcome; Ventricular tachycardia ablation; contrast-enhanced cardiac magnetic resonance; myocardial infarction; radiofrequency; Ce-MDCT; HR; LV; SPECT; conducting channel; electroanatomic map; Ventricular tachycardia ablation; infarct transmurality; left ventricle/ventricular; MI; implantable cardioverter-defibrillator; Epicardial approach; CC; computed tomography; ventricular fibrillation; CI; E-DC; electrogram with delayed component; ce-CMR; ICD; IT; EAM; VF; CT; RF; ventricular tachycardia; hazard ratio; confidence interval; contrast-enhanced multidetector computed tomography; single-photon emission computed tomography; VT; Infarct transmurality
• ISSN: 1547-5271; 1556-3871
• DOI: 10.1016/j.hrthm.2015.07.010

Background There is no consensus on the appropriate indications for the epicardial approach in substrate ablation of post–myocardial infarction (MI) ventricular tachycardia (VT). Objective The purpose of this study was to investigate whether infarct transmurality (IT) could identify patients who would benefit from a combined first-line endo-epicardial approach. Methods Before ablation, IT was assessed by contrast-enhanced cardiac magnetic resonance imaging (hyperenhancement ≥75% of the wall thickness in ≥1 segment), echocardiography (dyskinesia/akinesia + hyperrefringency + wall thinning), computed tomography (wall thinning), or scintigraphy (transmural necrosis). Prospectively from January 2011, an endocardial approach was used in patients with subendocardial MI (group 1) and a combined endo-epicardial approach in patients with transmural MI (group 2). Outcomes in both groups were compared with those in patients with transmural MI and only endocardial approach due to previous cardiac surgery or procedure performed before January 2011 (group 3). The primary end point was VT/ventricular fibrillation recurrence-free survival. Results Ninety patients (92.2% men; mean age 67.4 ± 9.8 years) undergoing VT substrate ablation were included: group 1, n = 34; group 2, n = 24; group 3, n = 32. During a mean follow-up duration of 22.5 ± 13.7 months, 5 patients in group 1 (14.7%), 3 patients in group 2 (12.5%), and 13 patients in group 3 (40.6%) had VT recurrences ( P = .011). Time to recurrence was the shortest in group 3 (log-rank, P = .018). The endocardial approach in patients with transmural MI was associated with an increased risk of recurrence (hazard ratio 4.01; 95% confidence interval 1.41–11.3; P = .009). Conclusion The endocardial approach in patients with transmural MI undergoing VT substrate ablation is associated with an increased risk of recurrence. IT may be a useful criterion for the selection of a first-line combined endo-epicardial approach.