Outcomes of Catheter Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy

Abstract

A rrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an inherited cardiomyopathy characterized by progressive fibrofatty replacement of the right ventricular myocardium. Structural abnormalities can be diffuse 1 and provide a substrate for reentrant ventricular tachycardia (VT). Studies have shown a significantly high incidence of ventricular arrhythmias 2-4 among patients with ARVD/C. Although the risk of sudden death is mitigated by implantable cardioverterdefibrillator (ICD) implantation, recurrent ICD firings due to rapid ventricular arrhythmias are common 5 and often a cause of significant morbidity in these patients. Radiofrequency catheter ablation (RFA) is increasingly used in the management of VT in ARVD/C. Early studies evaluating the efficacy of catheter ablation of VT among patients with ARVD/C reported varied outcomes using an endocardial-based ablation strategy and have mostly reported outcomes performed in referral centers specialized in VT ablation. [6][7][8][9] However, there have been recent advances in the technology related to catheter ablation and a better understanding of the VT substrate in ARVD/C. The reasons for failure after catheter ablation of VT are attributed to predominant epicardial distribution of the disease, existence of multiple reentrant pathways, and possibly a progressive disease process. In keeping with these findings, several recent studies have reported significantly lower VT recurrence among patients with ARVD/C who underwent an epicardial substratebased ablation strategy. 10,11Clinical Perspective on p 505The purpose of the present study was to report multicenter outcomes of catheter ablation of VT in a large series of patients with ARVD/C who were enrolled in the Johns Hopkins ARVD Registry (www.arvd.com). There were 3 main goals: (1) to determine whether catheter ablation outcomes for ARVD/C have improved with use of electroanatomic Received October 28, 2011; accepted March 19, 2012. The overall objective of the present study was to assess the efficacy of radiofrequency catheter ablation (RFA) of VT in ARVD/C, with particular focus on newer ablation strategies, including epicardial catheter ablation. Methods and Results-The study population included 87 patients with ARVD/C who underwent a total of 175 RFA procedures between 1992 and 2011 at 80 different electrophysiology centers. Recurrence of VT following RFA and effect of RFA on the burden of VT were assessed. The mean age of the cohort was 38±13 years. Over a mean followup of 88.3±66 months, the overall freedom from VT of the 175 procedures was 47%, 21%, and 15%, at 1, 5, and 10 years, respectively. The cumulative freedom from VT following epicardial RFA was 64% and 45% at 1 and 5 years, respectively, which was significantly longer than endocardial RFA (P=0.021). Survival free of VT among procedures with 3D electroanatomic mapping was significantly longer compared to those without (P=0.016). Burden of VT was reduced irrespective of the ablation strategy (P<0.001). Conclusions-Although

Right ventricular dysplasia: management and treatment in light of current evidence

“…However, RFA can be considered as an adjuvant therapy to ICD placement in patients with VT or frequent ICD firing despite using BB or antiarrhythmic drugs or in patients who were not able to tolerate ARVC recommended medications (class I) [22]. Furthermore, multiple electrophysiologic mapping techniques have been used to treat VA including voltage mapping and substrate mapping [31,32,46–48]. …”

Role of Ventricular Tachycardia Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy

“…Modern studies providing long term follow-up on large number of patients, 37,38 reported very high recurrence rates after the first procedure despite a combined endo/epicardial approach, although the cumulative freedom from VT following procedures using 3D-EVM and/or epicardial approach was significantly greater than conventional ablation. The most likely reason is the progressive nature of the disease with modification of the arrhythmic substrate over time.…”

Long‐term outcomes of catheter ablation of ventricular tachycardia in patients with structural heart disease

“…Although recent technological advances with electroanatomic and voltage mapping systems have significantly improved outcomes [27][28], catheter ablation can reduce the frequency of VT episodes, but long-term follow-up studies have demonstrated a risk of recurrence. However, only an endocardial approach was used in most of the cases previously reported [29][30][31].…”