DOI: 10.1161/CIRCEP.115.002827
Endo-Epicardial versus Only-Endocardial Ablation as a First Line Strategy
for the Treatment of Ventricular Tachycardia in Patients with
Ischemic Heart Disease
Running Title: Izquierdo et al.; Epicardial ablation of Ischemic VT
Maite Izquierdo, MD1; Juan Miguel Sanchez-Gomez, MD1; Angel Ferrero de Loma-Osorio,
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
PhD1; Angel Martínez, MD1; Alejandro Bellver, PhD2; Antonio Pelaez, PhD3; Julio Nuñez,
PhD1; Carlos Nuñez, MD1; Javier Chorro, PhD1; Ricardo Ruiz-Granell,
l,, P
PhD
h 1
hD
1
Hospital
H
Hosp
ospital Clinico Universitario, Valenc
Valencia;
nciia; 2Hospital Ge
nc
G
General,
nerall, Castellón;
3
Hospital
Hosp
Ho
spit
sp
ital
it
al D
Doctor
octo
octo
tor Pe
P
Peset,
seet,, V
Valencia,
alen
al
enci
en
ciaa, Sp
ci
Spai
Spain
aiin
Correspondence:
Corresp
pon
onde
denc
de
ncee:
nc
Maite
M
aite Izquierdo, MD
Av/ Hospital Clínico Universitario
Servicio de Cardiología
Blasco Ibañez 17
46010, Valencia
Spain
Tel: 0034 647097904
Fax: 0034 963862600
E-mail: [email protected]
Journal Subject Codes: [22] Ablation/ICD/surgery, [5] Arrhythmias, clinical electrophysiology,
drugs, [7] Chronic ischemic heart disease
1
DOI: 10.1161/CIRCEP.115.002827
Abstract:
Background - Epicardial ablation has shown improvement in clinical outcomes of patients with
ischemic heart disease (IHD) after ventricular tachycardia (VT) ablation. However, usually
epicardial access is only performed when endocardial ablation has failed. Our aim was to
compare the efficacy of endocardial+epicardial ablation versus only endocardial ablation in the
first procedure in patients with IHD.
Methods and Results - Fifty three patients with IHD, referred for a first VT ablation to our
institution, from 2012 to 2014, were included. They were divided in 2 groups according to
enrolment time: from May 2013, we started to systematically perform endo-epicardial access
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
(Epi-Group) as first-line approach in consecutive patients with IHD (n=15). Patients who
underwent only
y an endocardial VT ablation in their first procedure
p
((Endo-Group)
p) included:
(n=35).
latepatients with previous cardiac surgery and the historical (before May 2013) (n=3
35)
5).. Al
Alll la
late
te-te
potentials in the scar zone were eliminated and if VT was tolerated critical isthmuses were also
approached.
The
ap
ppr
proa
oached
hed
ed.. T
hee eendpoint
ndpoint was the non-inducibility
non-inducibiliity
y of
of any VT. During
Duuri
r ng a median
median follow-up of
(hospital
admission
115±10
5±
±10 months, the
t e combined
th
co
omb
mbin
ineed
in
ed eendpoint
ndpo
ndpo
poin
i t (h
in
hosppita
taal orr eemergency
meerg
gen
ncy
y adm
dmiissi
dm
sion
on because
beccau
ausse of
of a ventricular
vent
vent
ntri
ricu
ri
c la
cu
l
tachycardia
re-ablation)
occurred
patients
Endo-group
patient
ach
chyc
y ardia or re
e-aablattio
on) occ
ccur
cc
u redd in
i 144 pa
ati
tieents off the
th
he En
Endo
o-grrouup and
ndd iinn one
on pati
tiien
nt in
n thee
Epi-group
Epi-g
grooup (event-free
(even
entt-ffree
free ssurvival
urvi
rv vall curves
c rv
cu
rves by Grey-test,
Grey
Gr
ey-teest
st,
t p= 00.03).
.03
03).
03
) Ventricular
Ventr
triicul
tr
icullar arrhythmia
arr
rrhy
hyth
thmi
th
mia recurrences
mi
reecurr
rren
ence
cess
patients
Epi-Group
p=0.2).
occurred
d iin
n 16 aand
nd iin
n 3 pa
pati
tien
ti
ents
en
ts iin
n the
the En
Endo
do and
and E
pi--Gr
pi
Grou
oupp respectively
ou
resp
re
spec
sp
ecti
ec
tive
ti
vely
ve
ly ((Grey-test,
Grey
Gr
ey--te
ey
test
st,, p=
st
p=0.
0 2)
0.
2.
Conclusions
- A combined
ablation
ablation
Co lusions
Concl
i
combi
bined
d endocardial-epicardial
endocardi
d
dial-epi
l icardi
diall abl
blati
tion
i approachh ffor
or iinitial
niiti
itiall VT abl
blati
tion was
associated with fewer readmissions for VT and repeat ablations. Further studies are warranted.
Key words: ablation, ventricular tachycardia, epicardial
2
DOI: 10.1161/CIRCEP.115.002827
Introduction
Epicardial substrate ablation of ventricular tachycardia (VT) as a first-line option has shown to
improve outcome, in terms of VT recurrences, in many cardiac diseases as nonischemic dilated
cardiomyopathy1 and arrhythmogenic right ventricular dysplasia2-4. However, the role of this
approach in patients with ischemic heart disease (IHD) has not been clearly defined. Several
studies including patients with IHD that undergo epicardial ablation for VT have shown
improvement in clinical outcomes, but in these patients the epicardial access is usually
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
performed in a second or third procedure , after an endocardial ablation has failed5-8.
The purpose of this study was to compare the efficacy of only-endocardial VT ablation to
combined endocardial and epicardial ablation in the same procedure in unselected
ed
d ppatients
atie
at
tieent
ntss wi
with
th
IHD
HD th
that
hat undergo
und
dergo
g their first VT ablation in our inst
go
institution.
tit
itution.
Methods
Met
M
ethods
Pati
Patient
ien
entt Po
Popu
Population
p la
lati
tion
ti
on
The pres
present
essen
entt an
anal
analysis
alys
al
ysis
ys
is iincludes
nclu
nc
lude
lu
dess al
de
alll pa
pati
patients
ien
ents
ts w
with
ithh IH
it
IHD
HD re
refe
referred
ferr
fe
rred
rr
ed tto
o ou
ourr in
inst
institution
stit
st
itut
it
utio
ut
ionn fr
io
from
om 22012
0122 to
01
to 2014
for a first ablation procedure of sustained monomorphic VT.
Since May 2013, we decided to prospectively perform both, endo and epicardial access as
a first-line approach, in all consecutive patients with IHD referred for their first VT ablation
procedure, except for contraindications. Baseline characteristics, safety and outcome of this EpiGroup were compared to patients who underwent only an endocardial VT ablation in their first
procedure (Endo-Group).
The Endo-Group finally included:
-
Patients with previous cardiac surgery in whom epicardial access was
contraindicated.
3
DOI: 10.1161/CIRCEP.115.002827
-
The historical cohort of consecutive patients with IHD referred to our institution for a
first VT ablation from 2012 to May 2013.
-
A small number of patients from May 2013 to 2014 who underwent only endocardial
ablation despite not having contraindications to epicardial ablation, because of
physician preference (usually related to the lack of experience in epicardial access
during the learning curve of the technique).
This study was approved by the Institutional Review Board and all patients signed an
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
informed written consent.
VT ablation
The procedure was performed under local anaesthesia and conscious sedation. A quadripolar
quuad
adri
ripo
ri
pola
po
larr
la
diagnostic
femoral
diagnoost
stic
ic ccatheter
atheete
at
terr was introduced via the right fem
mor
o al vein to the rightt vventricular
entricular apex. The
left
was
valve
eft vventricle
entricle w
as aaccessed
ccces
esse
sedd re
se
rretrogradely
trrog
ogra
rade
ra
d ly tthrough
de
h ou
hr
ough
g the
thhe aortic
aorrti
ticc va
valv
l e and/
lv
aand/or
nd/
d/or
or vvia
ia a ttransseptal
rans
ra
nsse
ns
sept
se
p al
approach.
left
ventricle
maps
using
ap
pprroa
o ch. Electroanatomical
Elec
e trroa
oanato
omicall le
eft ven
ntr
t iclle m
ap
ps were
werre oobtained
btainnedd us
bt
sin
ng CARTO
CA
ARTO
RTO 3 (Biosense
(Bio
osen
sensee
Webster,, D
Diamond
Bar,
USA)
iamo
ia
mo
ond
n Bar
ar,, CA
ar
CA,, US
SA)) or EnSite
tee NavX
Nav
avX
X (St
( t Jude
(S
Juude
d Medical,
Med
edic
ical
a , St Paul,
al
Pau
aul,, MN,
au
MN, USA).
USA
SA).
) For
).
ablation
Thermocool,
Celsius
abla
ab
lati
la
tion
ti
on 33.5-4
.5-44 mm saline-irrigated
.5
sal
alin
inee-ir
in
irri
ir
riga
ri
gate
ga
tedd tip
te
tip ablation
abla
ab
lati
la
tion
ti
on catheters
cat
athe
hete
he
ters
te
rs ((Navistar
Navi
Na
vist
vi
star
st
ar T
herm
he
rmoc
rm
ocoo
oc
ool,
oo
l, C
elsi
el
sius
si
us
Thermocool -Biosense Webster- or CoolFlex -ST Jude) were used. Simultaneous recordings of
ventricular bipolar electrograms (bandpass filtered 30-500 Hz) and 12-lead surface
electrocardiogram (ECG) were stored digitally (Prucka Cardiolab, GE Medical Systems,
Milwaukee, WI, USA). The procedures were performed under intravenous anticoagulation with
sodium heparin (initial bolus of 50-100 IU/kg followed by a 1000 IU/hour perfusion adjusted to
maintain the partial time of tromboplastine activated above 250 s).
If the VT was not incessant, VT was induced with programmed stimulation (high rate
pacing and extrastimlus test using two pacing cycles, up to three extrastimuli, from the right and,
4
DOI: 10.1161/CIRCEP.115.002827
if necessary, left ventricle) and number of morphologies was recorded.
Isovoltage maps of the left ventricle’s endocardium and also epicardium in the Epi-Group
were constructed. The voltage thresholds used to consider dense scar and border zone were 0.5
and 1.5mV, respectively. Regions with late potentials inside or in the borders of a scar were
annotated using colour tags. A first attempt of VT induction was always performed. Points with
QRS morphology during pace-mapping identical to that during documented VT were also
annotated. When VT was present or induced and it was hemodinamically well tolerated,
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
activation maps and entrainment-mapping techniques were performed trying to characterize the
arrhythmia circuit. Radiofrequency energy was delivered in the power control mode through the
irrigated
rrigated tip catheters using a Stockert or Irvine generator with power set to 30-500 w an
andd
irrigation
ml/min. Radiofrequency lesions
rrigati
t on sett to 17-30
17
lesio
ions were created either
eith
her during VT or sinus
rhythm
critical
sustenance
clinical
hytthm in the
th
he regions
reegi
gion
o s identified
on
iden
id
enti
en
tifi
ti
f ed or
or supposed
supp
su
ppos
pp
o ed to
to be cr
ritica
call fo
ca
forr th
tthee su
ust
sten
en
nan
ance
c ooff cl
clin
inic
in
icall oorr
ic
inducible
end-point
was
the
all
nduuci
c ble VTs.
VT
Ts.
s Th
The en
nd--poin
nt w
as th
he eelimination
liimin
nattion off al
ll la
late
tee ppotentials
oten
ntiials in
n tthe
hee endocardial
endocaarddiaal sscar
carr
Epi-Group.
inducibility
and also in
in the epicardial
epicardi
ep
d al
di
a scar in
n the Epi
p -Grooup
u . Lack
Lac of in
nducibility
ty of anyy VT
V after
after ablation
considered
success;
was
inducibility
faster,
wass co
wa
cons
nsid
ns
id
der
ered
ed aacute
cute
cu
te pprocedural
roce
ro
cedu
ce
dura
du
rall su
ra
succ
cces
cc
ess;
es
s; ppartial
arti
ar
t al
ti
a success
suc
ucce
cess
ce
ss w
as ddefined
efin
ef
ined
in
ed aass in
indu
duci
du
c bi
ci
b li
lity
ty ooff fa
fast
ster
st
er,,
er
nonclinical VT. In patients with induced, not tolerated VT before ablation that needed more than
two DC shocks to be cardioverted, postprocedure inducibility was not sistematically tested.
Pericardial access
The pericardium was accessed percutaneously using the technique described by Sosa et al.9 once
the venous and arterial accesses were gained, and prior to start intravenous anticoagulation. As
stated before, pericardial access wasn´t performed in patients with previous cardiac surgery.
Before epicardial ablation, coronary angiography was performed to avoid coronary artery
damage. Epicardial phrenic nerve capture was tested with bipolar pacing from the ablation
5
DOI: 10.1161/CIRCEP.115.002827
catheter. When epicardial position of the ablation catheter was too close to a coronary artery or
when phrenic capture was obtained from it, the catheter was slightly moved trying to avoid
damage of such structures. If imminent damage was suspected radiofrequency wasn’t delivered.
Clinical outcome and Follow-up
All patients without previous ICD implant were implanted before discharge except for one
patient in the Epi-group with important pulmonary comorbidity. All patients were followed in
the outpatient clinic at three months and then every six months after ablation.
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
Endpoints
Primary endpoints were:
1) VT recurrence, that included an ICD appropriate therapy (antitachycardiaa ppacing
a in
ac
ingg or
shock)
k) orr a documented, slow, symptomaticc VT not detected by tthe
h ICD.
he
combined
included:
admission
22)) A comb
mbin
mb
ined
in
e eend-point
nd-p
nd
-poi
-p
ointt tthat
oi
hatt in
ha
incl
clud
cl
uded
ud
d: ho
hhospital
spiitaal
al orr emergency
emer
em
erge
er
g nc
ncyy ad
admi
miss
mi
ssionn because
ss
beca
be
caus
ca
u e of a nnew
us
ew
episode
episod
de of
of VT orr the nneed
eed off a ssecond
eccondd aablation
blaatioon procedure.
proce
ro edure..
3) Mortality
Mo
y for any
any cause.
e..
Statistical
analysis
Stat
St
atis
at
isti
is
tica
ti
call an
ca
anal
alys
al
ysis
ys
is
Continuous variables were expressed as median and interquartilic range (IQR). Discrete
variables were summarized as percentages. Baseline characteristics were compared between EpiGroup and Endo-Group using non-parametric tests (Fisher´s exact test and Mann-Whitney Test
for categorical and continuous variables respectively). An adapted version of Cox regression,
that takes into account the effect of all-cause mortality as competing event 10, was used to
examine the univariated association between baseline variables and both endpoints (VT
recurrence and the combined end-point).
The univariate effect of the combined epi/endo ablating strategy (Epi-Group) on the
6
DOI: 10.1161/CIRCEP.115.002827
incidence of the end-points (VT recurrence and combined end-point) was analyzed by the Fine
and Gray10 event-free survival curves.
The interaction in the Epi-Group prognosis of those variables that significantly differed in
baseline characteristics between groups (in particular previous cardiac surgery) was also studied
and for that purpose a second sensitivity analysis excluding patients with previous cardiac
surgery was performed. A multivariate test was not considered as none of the candidate covariables had p<0.15 in the univariate analysis and because of the small sample size. Estimated
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
survival curves in both groups (Endo- and Epi- groups) were assessed by Kaplan-Meier analysis
and differences between strata were assessed by Log-rank test. Univariate Cox-regression model
was performed to find if there were any baseline characteristics that predicted mortality
moorta
tali
ta
liity ffor
or aany
ny
cause. After tthat,
hat,
t, a second sensitivityy analysis excl
excluding
lud
u ing patients with pr
prev
previous
e ious cardiac surgery
w
ass performe
ed..
was
performed.
A 2-sided
2-sid
ided
d p-value
p-vaalue
ue of <0.05
<0
was
w s co
wa
considered
onsiide
ideredd to
o be
be st
sstatistically
tattissticaallyy sign
significant
niffic
i ant
ant for all
alll analyses.
an
nalysees..
Statistica
Statistical
al analyses
analy
lyse
ly
s s were
se
weere performed
perform
rmed usingg STA
rm
STATA
TATA
TA
TA 13.1
13.
3 1 (StataCorp.
( ta
(S
tataCorpp. 20
22013.
13. St
Stata
tat
a a St
Statistical
Soft
So
fttwa
ware
re:: Re
re
Rele
leeas
asee 13
13.1
.1.. Co
.1
Coll
lleg
egee St
eg
Stat
atio
at
io
on, TX:
TX: S
tata
ta
taCo
ta
Corp
Co
rp L
P)).
Software:
Release
13.1.
College
Station,
StataCorp
LP).
Results
From January 2012 to December 2014, 53 patients with IHD were referred for their first VT
ablation procedure. Thirty-five patients underwent only endocardial ablation:
-12 patients because they had had previous cardiac surgery,
-12 patients included from January 2012 to May 2013 when a combined procedure, endo and
epicardial access, was not being performed as a first attempt yet
- 8 patients from May 2013 that underwent only endocardial ablation, 7 because of physician
7
DOI: 10.1161/CIRCEP.115.002827
decision as it is explained in methods and 1 patient because of skin lesions in the
subxifoid area that contraindicated subxifoid access.
-3 patients in whom epicardial access failed (two of them because of the existence of
pericardial adhesions)
Figure 1 shows a flow-chart where the incorporation of patients is depicted.
Table 1 shows a comparison of the baseline characteristics between both groups. There
were no significant differences except for previous cardiac surgery, given that all operated
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
patients were in the Endo-Group.
Clinical Follow-up
Complete clinical follow-up was available for all but 1 patient that was lost after moving
mov
o in
ingg to
another
country.
The
anothe
er coun
ntry.
y T
he median follow-up was 397 (I
(IQR
Q 233-637) days in the
th Endo-Group and 324
(IQR
IQR
R 174-454)
174-454
544) days
day in
in the
the Epi-Group
E iEp
i-Gr
Grou
Gr
oupp (p=0.38).
ou
(p=0
(p
=0.3
=0
.38)
.3
8).
8)
Ablation
procedure
Abla
Ab
lation pro
la
ocedu
dure
du
ablation
targets
with
subsequent
Among the
th
he 15 patients
pat
a ientts in the Epi-Group,
Epi
pi-Group,
up,
p epi
pi and
andd eendocardial
n ocardi
nd
d al ablatio
on targ
getts wi
ith
t subsequ
q ent
radiofrequency
2).
adi
d of
o re
requ
quen
qu
ency
en
cy ddelivery
eliv
el
iver
iv
eryy we
er
were
re ffound
ound
ou
ndd iin
n 11 ppatients
atie
at
ieent
ntss (figure
( ig
(f
gur
uree 2)
). In 2 ppatients
atie
at
ient
ie
ntss on
nt
only
ly
y eendocardial
nddoc
ocar
ardi
ar
dial
di
a
al
targets were found although there were epicardial dense scars, and in 2 patients only epicardial
targets were encountered. Phrenic nerve capture and the proximity of coronary arteries did not
prevent any radiofrequency delivery.
There were no significant differences in acute complete success of ablation, 20 (57%) vs
6 (40%) patients in Endo and Epi-Group respectively (p=0.69). Induction of a non clinical
tachycardia occurred in 7 (20%) vs 5 (33%) in Endo and Epi-Group. Ablation failure, that is
induction of the clinical tachycardia, occurred in 2 patients (6%) in the Endo-Group and in 1
patient (7%) in the Epi-Group. Induction was not tried in 6 (17%) and in 3 patients (20%) of the
8
DOI: 10.1161/CIRCEP.115.002827
Endo and Epi-Group respectively.
The rest of the variables related to the procedure are displayed in table 2. There were no
significant differences between groups. The mean radiofrequency delivery time in the
endocardium was significantly shorter in the Epi-Group. However, total delivery time didn´t
differ between the two groups.
Complications
There were 4 local groin complications; two pericardial effusions in the Epi-group, one during
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
the endocardial mapping, before ablation, that needed drainage and finally required cardiac
surgery (this effusion was suspected to be produced by endocardial mapping ), and another that
occurred during epicardial mapping and that needed drainage (this second patient
nt uunderwent
nder
nd
erwe
er
went
we
nt a
second
pericardial
econdd only-endocardial
onlyy endo
docardial procedure because of peric
icardial adhesions).
VT recurrence
VT
recurrenc
n e
nc
During
follow-up,
the
Endo-Group
Remarkably
Duri
Du
ring
ri
n follow
w-upp, 16 (46%)
(46%) pa
(46
patientss off th
he En
Endo-Gr
Grouup had
Gr
hadd VT
VT recurrence.
reccurreenc
nce. R
emarka
kabblyy 5 off
ka
these
patients
symptomatic
that
were
the
needed
hospital
hese pati
tiien
e ts had
ad slow
w sy
symp
pto
oma
m tic VT tha
at we
ere uundetected
ndeteect
c ed byy th
he ICD,, 4 nee
ede
d d a hosp
pital
admission
admi
ad
miss
ssio
ss
io
on because
beca
be
caus
ca
usee of th
us
tthis
iss ssymptomatic
ympt
ym
ptom
pt
omat
om
atic
at
icc sslow
lo
ow VT aand
ndd one
one had
had a sl
slow
ow VT episode
epi
p so
sode
de bbefore
e or
ef
oree
discharge after ablation.
In the Epi-Group 3 (20%) patients had VT recurrences: 1 patient with a few episodes
reverted with antitachycardia pacing and 2 patients with an isolated VT episode requiring an ICD
shock. No slow, undetected VTs were registered.
Although a trend towards more VT recurrences in the Endo-Group was observed (figure
3A), no independent predictors of VT recurrence were found (table 3).
As it is displayed in figure 3A, the majority of recurrences occurred in the first 3 months
in both groups (2 of 3 in the Epi-Group and 10 of 16 in the Endo-Group).
9
DOI: 10.1161/CIRCEP.115.002827
Combined end-point (hospital or emergency admission or re-ablation)
The need of admission because of VT recurrence occurred in 13 (34%) patients of the EndoGroup (12 had a hospital admission and one patient attended the emergency department). One
patient of the Epi-Group attended the emergency department during follow-up. A second VT
ablation procedure was indicated in 10 (29%) patients of the Endo-Group and in none of the EpiGroup.
The occurrence of the combined endpoint (hospital or emergency admission because of
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
VT or re-ablation) was significantly lower in the Epi-Group (figure 3B). Baseline characteristics
between groups were comparable except for previous cardiac surgery, so the interaction was
studied
tudied and a second analysis excluding those patients was performed. Survival curves
currve
v s analysis
anal
an
alys
al
y is
i
showed
howed
e a trend
n ttowards
owards better outcomes excluding
ow
ngg these
the
h se patients (P=0.06)
(P=0.006)) (figure 4).
other
predictors
combined
No ot
the
herr pr
pred
dic
icto
tors
to
rs ooff th
thee co
comb
mbin
mb
ined
in
d eendpoint
n pooin
nd
nt we
were
re ffound
o ndd inn the
ou
the univariate
univar
un
arria
iate
te analysis
ana
n ly
lysi
siss (table
si
(tab
(t
able
ab
33).
)
).
Mortality
Mortalit
ty
Eleven
Endo-Group
were
heart
El
Elev
even
ev
en ppatients
atie
at
ieent
ntss (31%)
(31%
(3
1%)) of
1%
o tthe
hee E
nddoo Gr
Grou
oupp di
ou
ddied
ed dduring
urin
ur
ingg follow-up.
fooll
llow
ow-uup. Causes
ow
Cau
ause
sess of
se
o death
dea
eath
t w
th
eree he
er
hear
artt
ar
failure (6 patients) and lung cancer, intestine occlusion, pneumonia, sepsis and endocarditis over
a resynchronization therapy device with rapid heart failure after removal of the system (1 patient
each).
In the Epi-Group, only one patient died during follow-up because of tracheomalacia
secondary to a previous prolonged intubation. There were no significant differences in the
estimated cumulative risk of mortality between groups (Log Rank , p=0.17)
In the univariate analysis mortality was associated to previous cardiac surgery. Excluding
this subgroup, there were no significant differences in the estimated cumulative risk of mortality
10
DOI: 10.1161/CIRCEP.115.002827
between groups (log Rank=0.49)
Discussion
The main findings of this single-center experience are that a systematic combined access,
endocardial and epicardial, in consecutive, unselected patients with IHD that undergo their first
VT ablation procedure improve clinical outcome in terms of readmission because of VT and
reduce the need of re-ablation when compared to only endocardial ablation.
To our knowledge, all the published studies that assess the acute success and clinical
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outcomes of epicardial ablation of sustained monomorphic VT in IHD include patients that have
remains
consigned
a previous failed only-endocardial ablation procedure, so the epicardial access re
ema
main
inss co
in
cons
nsig
ns
igne
ig
n d
too a second step5-8. In these studies, a bias toward enriched epicardial substrates may be present,
gi
given
ive
venn that prior
pri
rioor endocardial ablation had failed.
ri
includes
unselected,
consecutive
that
underwent
This study
studdy systematically
systtem
maticcal
cally includ
des un
nseelecttedd, con
onse
on
secu
se
cu
utivee ppatients
atienntss th
hat unde
hat
erw
wentt
epicar
epicardial
rdi
dial
al aaccess
cces
esss in
in ttheir
h ir
he
ir ffirst
irst pprocedure.
roce
ro
ceduree. Th
Thee on
oonly
l rreason
ly
easo
ea
sonn to
to aaccede
cced
de or
o nnot
ott tto
o th
the
he epi
eepicardium,
picarrdi
dium
um,
previous
except ffor
or ccontraindications,
onttrai
on
trai
aind
ndic
nd
icat
ic
atio
at
ions
io
ns, was
ns
was the
the date
date of
of the
the procedure.
proc
pr
oced
oc
edur
ed
ure.
ur
e Only
Onl
nlyy a pr
prev
evio
ev
ious
io
us sstudy
tudy
tu
dy by
by Di Biase
Biase et
al11 compared a systematic endo-epicardial strategy in IHD patients with electrical storm to an
historical endo-ablation cohort. This study showed that an endo-epicardial approach reduced the
number of VT recurrences. However, the main limitation of the study of Di Biase et al was that
the ablation technique differed between groups: scar homogenization in the epi-group versus
limited substrate ablation in the historical cohort. Our series includes not only electrical storms
but all patients with sustained monomorphic VTs, and the same ablation technique was used in
both groups.
This systematic endo-epicardial approach in IHD patients could be justified by some
arguments: a) Different data point to increased electrophysiologists confidence with the
11
DOI: 10.1161/CIRCEP.115.002827
technique, that probably reflects the improvement in terms of security and the awareness of the
extent of epicardial involvement. 7 b) Epicardial and intra-mural re-entry circuit locations are
well recognized in the literature12-14 and are an important cause of failure of endocardial
ablation6. c) Improvements in outcome have been demonstrated when patients undergo an endoepicardial ablation in a second procedure after a first only endocardial ablation has failed.5 d)
Clinical and EKG characteristics have failed to reliably identify endocardial or epicardial
components of VT circuit in IHD.15
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So we speculated that an appropriate choice of a combined endo-epicardial approach as a
first line mapping and ablation strategy may avoid a substantial number of repeated procedures
and improve ablation outcome, as it has been demonstrated. Although we also observed
obbseerv
rved
ed a ttrend
rendd
towards
owardds a redu
reduction
d cttio
ion in ICD therapies with the endo
endo-epicardial
o-ep
e icardial approach we
w failed to demonstrate
a sig
significant
ignificant difference.
diff
di
ffer
ff
eren
er
nce
ce. However,
Howe
Ho
w ve
we
ver,
r, all
all hospital
hos
ospiita
tall admissions
adm
misssio
ons because
bec
ecau
use
se of
of VT aand
nd aall
ll rre-ablation
e-ab
ea laati
ab
tion
on
procedures
prrocced
e ures dur
during
u in
ng foll
follow-up
low
w-upp occurred
oc
e iin
ed
n the E
Endo-Group.
ndo-G
Grooup
up.
Itt mu
m
must
st be
be emphasized
emph
phas
ph
a ized tthat
h t epicardiall ttargets
ha
arrge
gets
ts were fo
ffound
und in 113
3 of 15 pa
patien
patients
ents in the Epien
Grou
Gr
oup,
ou
p, and
andd ttwo
wo of
of them
them had
had only
onl
nlyy epicardial
epic
ep
iccar
ardi
d al
di
a ttargets.
arge
ar
gets
ge
ts.. Although
ts
Alth
Al
t ou
th
ough
g it’s
gh
it’
t s true,
true
tr
ue,, on the
ue
thee one
one hand,
han
and,
d, tthat
haat the
t e
th
Group,
presence of abnormal electrograms that may not participate in reentry could overestimate
epicardial isthmuses, and only the number of terminated VT in the epicardium may be more real;
it’s also true, on the other hand, that most tachycardias are not hemodinamically tolerated and
cannot be mapped. Moreover, as Jaïs et al demonstrated, elimination of all late potentials is
associated with a superior clinical outcome.16
Surprisingly, acute success did not differ between groups in our series. Tung et al5 when
compared only-endo versus endo-epicardial ablation mainly in ischemic patients with previous
failed procedures reported a similar finding. Procedural endpoints may therefore be unreliable as
12
DOI: 10.1161/CIRCEP.115.002827
well. Lack of inducibility of VT after ablation does not unequivocally predict a better outcome
after ablation17,18. Although non-inducibility has been related to reduced mortality and VT
recurrences19, it is known that VT ablation doesn’t improve survival, so we can speculate that
non-inducibility can be seen as a well prognosis marker that may not be achieved in all patients.
In other series, VT ablation has failed to demonstrate a survival improvement20,21. In our
study, a reduction in terms of hospital admission because of a VT or need of re-ablation or even
a trend towards less VT recurrences in the Epi-Group didn´t associate with a mortality reduction.
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
The only predictor of mortality was previous cardiac surgery. As it is shown in table 3, previous
cardiac surgery was not a predictor of VT recurrence or the combined end-point. However, as
his subgroup of patients were all allocated in the Endo-Group, further statistical analysis
ana
n ly
na
ysi
siss was
wa
this
perfor
rme
m d re
emovi
ving this subgroup. Even then endo
o-epicardial ablation as a first step still showed
performed
removing
endo-epicardial
a tr
ttrend
end toward
rdss a be
rd
bbetter
ttter outcome
out
utco
c me in terms
co
terrms of
of ho
hospi
itaal admissions
adm
dmis
dm
issi
is
sion
si
o s and
and re-ablations.
ree ab
eablatiion
ons.
s
s.
towards
hospital
A curio
i uss ffinding
indiingg was
as tthat
h t 5 pa
ha
ppatients
tieents inn thee Endo-Group
Endo
do-G
do
-Grrouup and
-G
andd none
nonne in
in the
the Epi-Group
Epii-G
-Grooupp had
haad
ad a
curious
ecurrence
ce in thee form
m ooff slow VT
VT undetected
ed
d bby
y the
the ICD.. There aree few stu
udi
d ess iincluding
ncludingg
recurrence
studies
pati
pa
t en
ti
ents
ts with
witth slow
s ow VT
sl
VT that
t at show
th
shoow that
t at these
th
theese ppatients
atie
at
ieent
ntss have
haave a w
orse
or
se pprognosis
rogn
ro
gnos
gn
osis
os
iss iin
n te
term
rmss of V
rm
T
patients
worse
terms
VT
recurrence and even mortality22,23.
Finally but not less important is that two patients had significant pericardial bleeding in
the Epi-group, a percentage already described in the literature6,24, so it must be emphasized that
the procedure should be performed by experienced operators with surgical back-up.
Limitations
The major limitations of our study are:
1. It is not a randomized study, however the patients that underwent epi+endo ablation were
unselected and the assigned access depended in most of them only on the time period.
13
DOI: 10.1161/CIRCEP.115.002827
Moreover, there were no significant differences in baseline characteristics, but for previous
surgery, between both groups.
2. No surgical epicardial ablation was performed, so patients with previous surgery were
included in the Endo-Group. However the interaction of previous surgery for the combined
end-point was not significant.
3. It reflects only the practice in a single center but, just because of this, the ablation
technique is homogeneous in all the patients
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4. The sample is small and the follow up period in the Epi-Group is short, especially when
compared to the Endo-Group. Thus our series must be taken as an hypothesis generating
study or as a feasibility study.
5. The co
ccomposite
mp
pos
o ite end-point (hospital or emergency
emerg
rg
gen
e cy admission becau
because
ause
s of VT or re-ablation)
iiss not a hard
har
ardd end-point
end-po
en
poin
po
intt and
in
a d could
an
coul
co
uldd be somehow
ul
som
meh
ehow subjective.
suubjeect
ctiv
ive.
iv
e.
Conclusions
Conc
clu
lusi
sion
si
ons
A comb
combined
bin
ined
ed endocardial
end
ndoc
ocar
oc
ardi
ar
dial
di
al and
and epicardial
epi
pica
carrdia
ca
rdia
iall approach
appr
ap
prooach
pr
oach iin
n th
thee fi
firs
first
rstt ablation
rs
abla
ab
lati
la
tion
ti
on procedure
pro
roce
cedu
ce
dure
du
re for
for m
monomorphic
onom
on
omorphic
om
sustained VT is feasible. It is not associated, in our limited series, to a significant reduction in
VT recurrence. However it is associated with a significant reduction in hospital and emergency
admissions because of VT recurrence and with the need of reablation in IHD patients. Further
studies are warranted.
Conflict of Interest Disclosures: None
References:
1. Cano O, Hutchinson M, Lin D, Garcia F, Zado E, Bala R, Riley M, Cooper J, Dixit S,
Gerstenfeld E, Callans D, Marchlinski F. Electroanatomic substrate and ablation outcome for
14
DOI: 10.1161/CIRCEP.115.002827
suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy. J
Am Coll Cardiol. 2009;54:799-808.
2. Garcia F, Bazan V, Zado E, Ren J, Marchlinski F. Epicardial substrate and outcome with
epicardial ablation of ventricular tachycardia in arrhythmogenic right ventricular
cardiomyopathy/displasia. Circulation. 2009;120: 366-375.
3. Bai R, Biase L, Shivkumar K, Mohanty P, tung R, Santangeli P, Saenz L, Vacca M, Verma A,
Khaykin Y, Mohanty S, Bukhardt D, Hongo R, Beheiry S, Russo A, Casella M, Pelargonio G,
Santarelli P, Sanchez J, tondo C, Natale A. Ablation of ventricular arrhythmias in
arrhythmogenic ritht ventricular dysplasia/cardiomyopathy: arrhythmia-free survival after endoepicardial substrate based mapping and ablation. Circ Arrhythm Electrophysiol. 2011;4:478-485.
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
4. Berruezo A, Fernandez-Armenta J, Mont L, Zeljko H, Andreu D, Herczku C, boussy T,
Tolosana J, Arbelo E, Brugada J. Combined endocardial and epicardial catheter ablation in
arrhythmogenic right ventricular dysplasia incorporating scar dechanneling technique. Circ
Arrhythm Electrophysiol. 2012;5:111-121.
5. Tung R, Michowitz Y, Yu R, Mathuria N, Vaseghi M, Buch E, Bradfield J, Fu
Fujimura
uji
jimu
mura
mu
ra O,
O, Gima
Gi
J, Discepolo W, Mandapati R, Boyle N, Shivkumar K. Epicardial ablation of ventricular
venttri
riccula
culaar
tachycardia:
achyccardia: An in
institutional experience of safety
y aand
n efficacy. Heart Rhythm.
nd
Rh
hyt
y hm. 2013;10:490–498.
6. Schimdt
Ouyang
F,, Ku
Schimdt B,
B, Chun
Chu KR,
KR, Baensch
Bae
a nssch D,
D, Antz
Ant M,
M, Koektuerk
K ekttuerrk B, Tilz
Ko
Tilzz R, Metzner
Met
etzn
zner A,
zn
A, Ou
Ouya
yang
ya
ngg F
Kuck
c
K.
Catheter
ventricular
after
failed
endocardial
ablation:
K. Ca
C
theter ablation
ablaatiion for
forr vent
ntri
nt
riculaar ttachycardia
ri
acchyycarrdiia af
fteer fa
fail
iled
il
ed
d en
ndoccardial ab
blat
atio
at
io
on: epicardial
eppic
picar
cardial
substrate
endocardial
Heart
ubsstr
t ate or inappropriate
ina
n pprropriiatte end
nddocardiial
a aablation?.
blatio
on?. H
eaartt Rhythm.
Rhyt
Rh
ytthm
m. 22010;7:1746-1752
0110;7:177466-11752 .
Bella
Neuzil
7. Della Be
B
lla P, Brugada
Bruga
gada
ga
d J,, Zeppenfeld
Zeepp
ppenfeld K, Merino
M ri
Me
rino
no JJ,, Neuz
uzil P,, Maury
uz
Maur
uryy P,, Maccabelli
ur
Mac
a caabe
b lli G,, Vergara
F,, Be
Berruezo
A,, Wi
Wijnmaalen
A.. E
Epicardial
ablation
P, Baratto
Barattto F
Berr
rrue
rr
uezo
ue
zo A
Wijn
jnma
jn
maaalen
ma
en A
p caard
pi
rdia
iall ab
ia
abla
lati
la
tion
ti
on ffor
or vventricular
entr
en
tric
tr
icul
ic
ular
ul
ar ttachycardia.
achy
ac
hyca
hy
card
ca
rdia
rd
ia. A
ia
European
Multicenter
Study.
2011;4:653-659.
Euro
Eu
rope
ro
pean
pe
an M
u ti
ul
t ce
cent
nter
nt
er S
tudy
tu
dy.. Ci
dy
Circ
rc Arrhythm
Arr
rrhy
hyth
hy
thm
th
m electrophysiol.
elec
el
ectr
ec
trop
tr
ophy
op
hysi
hy
siol
si
ol.. 20
ol
2011
11;4
11
;4:6
;4
:653
:6
53-6
53
-6659
59..
8. Yoshiga Y, Maathew S, wissner E, Tilz R, Fuernakranz A, Metzner A, Rilling A,
Konstantinidou M, Igarashi M, Kuck KH, Ouyang F. Correlation between substrate location and
ablation strategy in patients with ventricular tachycardia late after myocardial infarction. Heart
Rhythm. 2012;9:1192-1199.
9. Sosa E, Scanavacca M, D´Avila A, Oliveira F, Ramires JA. Nonsurgical transthoracic
epicardial catheter ablation to treat recurrent ventricular tachycardia occurring late after
myocardial infarction. J Am Coll Cardiol. 2000;35:1442-49.
10. Fine JP, Gray RJ. A Proportional Hazards Model for the Subdistribution of a
Risk. J Am Stat Assoc. 1999;94:495-509.
Competing
11. Biase L, Santangeli P, Burkhardt DJ, Bai R, Mohanty P, Cardbucichio C, Dello Russo A,
Casella M, Mohanty S, Pump A, Hongo R, Beheiry S, Pelargonio G, Santarelli P, Zucchetti M,
Horton R, Sanchez JE, Elayi CS, Lakkireddy D, Tondo C, Natale A. Endo-epicardial
15
DOI: 10.1161/CIRCEP.115.002827
homogenization of the scar versus limited substrate ablation for the treatment of electrical storms
in patients with ischemic cardiomyopathy. J.Am Coll Cardiol. 2012;60:132-141.
12. Kaltenbrunner W, Cardinal R, Dubuc M, Shenasa M, Nadeau R, Tremblay G, Vermeulen M,
Savard P, Page PL. Epicardial and endocardial mapping of ventricular tachycardia in patients
with myocardial infarction. Is the origin of the tachycardia always subendocardially localized?.
Circulation. 1991;84:1058-1071.
13. Littmann L, Svenson RH, Gallagher JJ, Selle JG, Zimmem SH, Fedor JM, Colavita PG
Functional role of the epicardium in postinfarction ventricular tachycardia. Observations derived
from computerized epicardial activation mapping, entrainment, and epicardial laser
photoablation. Circulation. 1991;83:1577-1591.
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
14. Josephson ME, SimsonMB, Harken AH, Horowith LN, Falcone RA. The incidence and
clinical significance of epicardial late potentials in patients with recurrent sustained ventricular
tachycardia and coronary artery disease. Circulation. 1982, 66:1199–1204.
15. Martinek M, Stevenson W, Inada K, Michifumi T, Tedrow U. QRS characteristics
characterissti
ticcs ffail
aill to
ai
t
reliably
ischemic
heart
eliably identify ventricular tachycardias that require epicardial ablation in ischemi
micc he
mi
hear
artt
ar
disease. J Cardiovasc Electrophysiol. 2012;23:188-193.
16.
Hocini
16
6. Jaïs
Jaïïs
Ja
ïs P,
P, Maury
Maurry P,
Ma
P, Khairy P, Sacher F, Nault I, Ko
Komatsu Y,, Hoci
cini M,
ci
M, Forclaz
Forclaz A, Jadidi A,
Weerasooryia
R,, sh
Derval
N,, co
cochet
H,, Kne
Knecht
L,, wr
wright
W
Wee
eerasooryia
iaa R
sshah
ah A,
A, De
Derv
val N
och
chet H
echht S,
S, Miyazaki
Miya
Mi
yazaaki S,
ya
S, Linton
Lint
Li
nton
nt
o N,
N, rivard
riva
ri
vard
va
r L
wrig
ight
ig
h
ht
M,, w
wilton
Scherr
D,, P
Pascale
L,, P
Pederson
Laurent
S,, rit
ritter
P,,
M
ilton S, Sch
herrr D
ascaale P, Ro
Rotenn L
ed
dersonn M,
M bbordachar
orddachaar
or
ar P, La
aurren
nt ff,, Kim
im
mS
tter P
climenty
Haïsaguerre
Elimination
activities:
point
cl
lim
imen
e ty J, Ha
Haïsag
aguerrre M. E
ag
liimi
m naati
tion
on
n of
of local
lo
ocaal abnormal
ab
bnorm
mal vventricular
en
ntriccullar ac
ctiv
vittiess: a new
ew end
nd po
oinnt
substrate
modification
scar-related
ventricular
tachycardia.
Circulation.
forr su
subs
bstr
bs
trat
tr
atee mo
at
modi
d fi
di
fica
cattion
ca
on in patients
pati
pa
tien
ti
nts
ts with
wit
ithh sc
scar
ar--re
ar
rela
lateed ve
la
vent
ntri
nt
ricu
ri
cula
cu
larr ta
ach
chyc
ycarrdi
yc
d a.
a Ci
Circ
rcul
rc
ulattion
ion.
2012;4:653-659.
2012;4:6
653
5 -6599.
17.
Coll
Cardiol.
2012;
17
7. Bogun
Bogu
Bo
gunn F. Ablation
gu
Abl
b at
atio
ionn for
io
foor ventricular
vent
ve
ntri
nt
ricu
cula
cu
laar tachycardia.
tach
ta
c yc
ch
ycar
ardi
ar
d a. J Am C
di
olll Ca
ol
Card
rdio
rd
ioll. 20
io
2012
12;; 2:142-143.
12
2:14
2:
14214
2 14
2143.
3.
18. Tung R, Josephson ME, Reddy V, Reynolds MR. Influence of clinical and procedural
predictors on ventricular tachycardia ablation outcomes: an analysis from the substrate mapping
and ablation in sinus rhythm to Halt Ventricular Tachycardia Trial (SMASH VT). J Cardiovasc
Electrophysiol. 2010;21:799-803.
19. Carbuccio C, santamaria M, Trevisi N. catéter ablation for the treatment of electrical storm in
patients with implantable cardioverter-defibrillators: short-and long-term outcomes in a
prospective single-center study. Circulation. 2008;117: 462-469.
20. Izquierdo M, Ruiz-Granell R, Ferrero A, Martínez A, Sánchez-Gomez JM, Bonanad C,
Mascarell B, Morell S, García-Civera R. Ablation or conservative management of electrical
storm due to monomorphic ventricular tachycardia: differences in outcome. Europace.
2012;14:1734-1739.
16
DOI: 10.1161/CIRCEP.115.002827
21. Mallidi J, Nadkarni GN, Berger RD, Calkins H, Nazarian S. Meta-analysis of catheter
ablation as an adjunct to medical therapy for treatment of ventricular tachycardia in patients with
structural heart disease. Heart Rhythm. 2011;8:503–510.
22. Izquierdo M, RuizGranell R, Ferrero A, Martínez A, Dominguez E, Madrazo I, Cuenca I,
Garcia Civera R.Valor pronóstico de la taquicardia ventricular lenta en portadores de DAI por
prevención secundaria. Rev Esp Cardiol. 2011;64(Supl 3):283.
23. Worck R, Haarbo J, Thomsen PE. Electrophysiological study and slow ventricular
tachycardia predict appropriate therapy: results from a single-centre implantable cardiac
defibrillator follow-up. Europace. 2007;9:1048-1053.
24. Mohani G, Israel C, Casella M, Carbucchio C. Epicardial ablation as a bailout in electrical
storm?. Herzschr Elektrophys. 2014;25:93-101.
Downloaded from http://circep.ahajournals.org/ by guest on July 28, 2017
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DOI: 10.1161/CIRCEP.115.002827
Table 1: Baseline patient characteristics
N
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Age (y)
Sex: Male
Ejection Fraction
QRS duration
Hypertension
Creatinin
Dyslipemia
Smoker
Ex smoker
Diabetes
Previous atrial fibrillation
History of Heart failure Admission
Prev
evio
ev
ious
io
us IICD
CD
Previous
S
econdarry pr
prev
even
ev
ntiion
Secondary
prevention
R
esynchronizat
sy
tio
on T
heerapyy
Resynchronization
Therapy
Pr
revi
vious Cardiac
Caard
r ia
ac Surg
rgery
rg
Previous
Surgery
B
By
pass
pa
Bypass
Valv
vul
ulaar
ar
Valvular
Anti
An
tiar
ti
arrh
ar
rhyt
rh
ythm
yt
hmic
hm
icss po
ic
post
st-ab
st
abla
ab
lati
la
tion
ti
on
Antiarrhythmics
post-ablation
A
i d
Amiodarone
Sotalol
Betablockers
Furosemide
Oral antiarrhythmics pre-ablation
Furosemide
Qualifying episode:
First VT episode
Presentation as a VT storm
Presentation as a cardiac arrest
Lone VT episode
Syncope
Endo-Group
35
Epi-Group
15
p
0.82
66 (61-78)
33 (94%)
32 (28-41)
144 (107-156)
25 (71%)
1.08 (0.88-1.44)
23 (65%)
6 (17%)
16 (46%)
11 (31%)
11 (31%)
11(31%)
22 (63%)
(633%)
13 ((56%)
56%
%)
6 (18%)
(1 )
67 (64-78)
14 (94%)
30 (22-41)
119 (100-153)
13 (86%)
1.19(0.94-1.54)
11 (73%)
3 (20%)
7 (47%)
5 (33%)
4 (27%)
3 (23%)
10 (67
67%)
67
%
(67%)
5 (5
((50%)
0%
%)
2 (14%
4%
%)
(14%)
1.00
0.38
0.46
0.30
0.45
0.74
1.00
1.00
1.00
0,22
0.72
0.
72
1111 ((31%)
31%)
31
%)
(3%)
1 (3%)
0
0
00.03
.03
03
-
16 (46%)
7(20%)
31 (88%)
20 (57%)
5 (35%)
20 (57%)
7 (47%)
2(13%)
12 (85%)
11 (73%)
17 (48%)
11 (73%)
00.83
83
0.83
0.56
0.35
0.5
0.35
18 (51%)
12 (33%)
5 (14%)
9 (26%)
11 (31%)
6 (40%)
5 (33%)
2 (13%)
3 (20%)
5 (33%)
0.54
0.79
1.00
1.00
1.00
VT: ventricular tachycardia; ICD: implantable cardiac defibrillator.
Values are expressed as a median (interquartilic range) or n (percentage)
18
00.96
.96
96
1.00
0.80
0.
80
00.82
.882
DOI: 10.1161/CIRCEP.115.002827
Table 2: Procedure characteristics
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Endo-Group
Epi-Group
N
35
15
Carto System
19 (54%)
12 (80%)
0.11
NavX System
16 (45%)
3 (20%)
0.11
Procedure Time (h)
5.5 (5-6)
6 (5.5-6.5)
0.15
xRay time (min)
8 ( 6-11)
9 (8-14)
0.26
RF time (min)
19 (13-28)
16 (13-23)
0.34
Epicardial
p
-
6 (0-10)
(
)
-
Endocardial
19 (13-28)
10 (3-17)
0.01
0.
01
Scar
arr llocation
ocat
oc
atio
at
ionn
io
p
0.67
I ferior/ late
In
tera
te
ral/in
ra
nfe
f ro
ro--se
sept
ptal
pt
al
Inferior/
lateral/infero-septal
222
2 ((64%)
64%)
64
7 (53%
3%
%)
(53%)
-
Anterior
An orr
8 (23%)
(23%
(2
3%))
3%
4 (27%)
(27%
(2
7%))
7%
-
Apical
Apiccal
5 (14%)
(14%
(1
4%))
4%
4 (26%)
(26%
(2
6%))
6%
-
Number
Nu
b off VT iinduced
nduc
d ed
d
Number
2 (1
-3)
3)
(1-3)
3 (1
-3)
3)
(1-3)
00.44
.44
44
Ablation during VT episode
10 (29%)
4 (27%)
1.00
VT: ventricular tachycardia
Values are expressed as a median (interquartilic range) or n (percentage)
19
DOI: 10.1161/CIRCEP.115.002827
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Table 3: Predictors of VT recurrence and the combined end-point (hospital or emergency department admissions because of VT and
need of reablation)
Unadjusted Hazard Ratio for VT recurrence
Unadjusted HR for the combined end-point
Cox regression
HR (95% CI)
P-value
HR (95% CI)
P-value
Ejection Fraction*
0.82 (0.50, 1,36)
0.45
0.78 (0.45, 1.35)
0.38
Cardiac
iac Surgery
1.37 (0.84, 2.14)
0.23
1.13(0.61,2.92)
0.46
0.46
46
Hypertension
ertension
0.67 (0.25, 1.76)
0.42
2.59(0.46,14.72)
00.28
.28
28
Smoker
kerr
1.08 (0.66, 1.76)
0.76
11.5(0.81,2.93)
1.
5(0.81
811,2
,2.93)
0.19
Diabetes
etess
00.82
0.
82 (0.35,
(0.
0.35
35,, 2.
35
2.15
2.15)
15))
15
0.69
0.
.69
0.97
97 (0.30,3.13)
(0.
0 30,3
0.
30 3.13)
3))
0.96
0.
96
Age
0.97
0.9
97 (0.92,1.01)
(0.92,11.001)
0.16
0.
.16
0.96
0.9
96 (0.90,1.03)
(0.990,11.003)
00.28
.28
Creatinine†
tininee†
11.05
1.
05 (0.94,
(0.94
9 , 1.18
1.18)
18))
18
00.37
.337
00.99(0.86,
0.
99(0
99
(0.886, 11.14)
.114)
00.92
.92
92
First VT episo
episode
ode
1.70
1.
70 (0.68,
(0.
0.68
68,, 4.
68
44.14)
14))
14
00.25
.255
11.41(0.58,12.14)
1.
4 (0
41
(0.5
.58,
.5
8,12
8,
12..14)
12
4)
00.51
.51
QRS duration‡
durati
du
tion‡‡
11.08
.08
08 (0.92,
(0.92
92, 11.28)
92
.28
28))
28
00.33
.33
33
11.05
.0
05 (0.88,1.27)
05
(0.88
88,11.227))
00.54
.544
Anti-arrhythmic drug
2.07 (0.75, 5.73)
0.15
1.77(0.55,5.43)
0.35
VT: ventricular tachycardia; HR: Hazard Ratio; CI: confidence interval.
* For each 10% increase; † for each 0,1 mg/dl increase; ‡ for each 10ms increase
1
DOI: 10.1161/CIRCEP.115.002827
Figure Legends:
Figure 1: Patients flow-chart. *One patient had a pericardial efussion during epicardial mapping
and underwent a second procedure in which pericardial Access failed because of pericardial
adhesions. †Neither endocardial nor epicardial scar (the diagnosis of ischemic disease was
questioned)
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Figure 2: Epicardial (left) and endocardial (right) bipolar maps using Carto (panel A) and NavX
(panel B). The pink (panel A) and red marks (panel B) inside the scar identify late potential
zones .
Figure
Event-free
and
composite
end-point
Figu
Fi
ure 3: Eve
vent
ve
nt-f
nt
-fre
-f
r e survival
surv
su
rviv
rv
ivall curves
iv
cur
urve
vess for
ve
for VT
T rrecurrences
e urre
ec
rennces
re
ess ((left)
left
le
ft)) an
ft
nd th
thee co
comp
m ossit
itee en
endd po
poin
intt
in
(right).
rig
i ht).
ht
Figure
Event-free
Figu
Fi
gure
gu
re 44:: E
vent
ve
nt-fr
nt
free
fr
ee survival
sur
urvi
v va
vi
vall curves
curv
cu
rves
rv
es for
for VT
VT recurrences
recu
re
curr
cu
rren
rr
ence
en
cess (l
ce
((left)
e t) aand
ef
nd tthe
hee ccomposite
ompo
om
posi
po
s te eend-point
si
nd-p
nd
-poi
-p
oint
oi
nt
(right), excluding patients with previous surgery
1
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Endo-Epicardial versus Only-Endocardial Ablation as a First Line Strategy for the Treatment
of Ventricular Tachycardia in Patients with Ischemic Heart Disease
Maite Izquierdo, Juan Miguel Sanchez-Gomez, Angel Ferrero de Loma-Osorio, Angel Martínez,
Alejandro Bellver, Antonio Pelaez, Julio Núñez, Carlos Nuñez, F. Javier Chorro and Ricardo
Ruiz-Granell
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Circ Arrhythm Electrophysiol. published online June 8, 2015;
Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue,
Dallas, TX 75231
Copyright © 2015 American Heart Association, Inc. All rights reserved.
Print ISSN: 1941-3149. Online ISSN: 1941-3084
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circep.ahajournals.org/content/early/2015/06/08/CIRCEP.115.002827
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