Ablation of Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy

• DOI: 10.1161/circep.111.963066
• Publication Date: 2011-06-11T03:41:37Z
• Authors: Rong Bai; Luigi Di Biase; Kalyanam Shivkumar; Prasant Mohanty; Roderick Tung; Pasquale Santangeli; Luis Carlos Saenz; Miguel Vacca; Atul Verma; Yariv Khaykin; Sanghamitra Mohanty; J. David Burkhardt; Richard Hongo; Salwa Beheiry; Antonio Dello Russo; Michela Casella; Gemma Pelargonio; Pietro Santarelli; Javier Sanchez; Claudio Tondo; Andrea Natale
• Keywords: Adult; Male; Incidence; Middle Aged; Disease-Free Survival; Defibrillators, Implantable; 3. Good health; Electrocardiography; 03 medical and health sciences; Treatment Outcome; 0302 clinical medicine; Recurrence; Catheter Ablation; Tachycardia, Ventricular; Humans; Female; Prospective Studies; Electrophysiologic Techniques, Cardiac; Pericardium; Arrhythmogenic Right Ventricular Dysplasia; Endocardium; Follow-Up Studies

Background— 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.

Methods and Results—

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].

Conclusions— 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.