Impact of New Technologies and Approaches for Post–Myocardial Infarction Ventricular Tachycardia Ablation During Long-Term Follow-Up

Abstract

Background— During the past years, many innovations have been introduced to facilitate catheter ablation of post–myocardial infarction ventricular tachycardia. However, the predictors of outcome after ablation were not thoroughly studied. Methods and Results— From 2009 to 2013, consecutive patients referred for post–myocardial infarction ventricular tachycardia ablation were included. The end point of the procedure was complete elimination of local abnormal ventricular activities (LAVA) and ventricular tachycardia (VT) noninducibility. The predictors of outcome with primary end point of VT recurrence were assessed. A total of 125 patients were included (age: 64±11 years; 7 women) for 142 procedures. The left ventricle was accessed via transseptal, retrograde aortic, and epicardial approaches in 87%, 33%, and 37% of patients, respectively. Three-dimensional electroanatomical mapping system was used in 70%, multipolar catheter in 51%, and real-time image integration in 38% (from magnetic resonance imaging in 39% and multidetector computed tomography in 93%) of patients. Before ablation, VT was inducible in 75%, and endocardial/epicardial LAVA were present in 88%/75%. After ablation, complete LAVA elimination was achieved in 60%, and VT noninducibility in 83%. During a median follow-up of 850 days (interquartile range, 439–1707), VT recurrence was observed in 36%. Multivariable analysis identified 3 independent outcome predictors: the ability to achieve complete LAVA elimination ( R 2 =0.29; P <0.0001; risk ratio=0.52 [0.38–0.70]), the use of real-time image integration ( R 2 =0.21; P =0.0006; risk ratio=0.49 [0.33–0.74]), and the use of multipolar catheters ( R 2 =0.08; P =0.05; risk ratio=0.75 [0.56–1.00]). Conclusions— Achievement of complete LAVA elimination and use of scar integration from imaging and multipolar catheters to focus high-density mapping are independent predictors of VT-free survival after catheter ablation for post–myocardial infarction ventricular tachycardia.

Utility of high density multielectrode mapping during ablation of scar‐related ventricular tachycardia

“…Yamashita et al. evaluated the impact on ablation outcomes of different recently incorporated technologies in 125 patients with post myocardial infarction VT (MI‐VT), including the use of multielectrode catheters (n = 73) . In multivariate analysis they found that the use of a multielectrode catheter was an independent predictor of better outcome after VT ablation (R 2 = 0.08; P = 0.05; risk ratio 0.75 [0.56–1.00]).…”

Optimal Ablation Techniques for Ventricular Tachycardia Management

“…47 Complete LAVA elimination, the use of realtime image integration, and high-density mapping with multipolar catheters were independent predictors of VT free survival after catheter ablation for post-myocardial infarction VT (Figure 7). These findings strongly suggest that complete LAVA elimination is a predictive procedural endpoint associated with a twofold reduction in VT recurrence.…”

“…Overall, the impact of multipolar catheter use on patient outcomes seems to be mediated by a more comprehensive characterization of the VT substrate, which translated to a lower VT recurrence rate following catheter ablation. 41,47 …”

“…An ablation strategy guided by abnormal potentials, coupled with local voltage profile analysis (Table 1), has been shown to be an effective strategy of VT control in patients with structural heart disease, particularly in those with ICM. 47,48,57 With high-density mapping and extensive ablations across the endocardial ± epicardial surfaces, the elimination of all LAVA may be achieved in B70% of patients. 57,58 Complete LAVA elimination is associated with a reduction in recurrent VT or death (p = 0.035) compared with the persistence of LAVA (Figure 7), and represents a useful and effective procedural endpoint for substrate-based VT ablation.…”

“…Imaging integration provides important complementary information to electroanatomical mapping, particularly in patients with NICM or in those under going epicardial ablations. 47,64 The structural abnormality may be segmented as areas of delayed gadolinium enhancement on MRI, and/or as areas of wall thinning on multidetector CT scan, and are correlated with local conduction delay defined by late potentials or LAVA. 37,65 Real-time image integration for substrate localization/characterization for VT ablation will soon become an accepted standard.…”