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Long-Term Outcome After Catheter Ablation of Ventricular Tachycardia in Patients With Nonischemic Dilated Cardiomyopathy
Long-Term Outcome After Catheter Ablation of Ventricular Tachycardia in Patients With Nonischemic Dilated Cardiomyopathy
Long-Term Outcome After Catheter Ablation of Ventricular Tachycardia in Patients With Nonischemic Dilated Cardiomyopathy
Background—Catheter ablation (CA) of ventricular tachycardia (VT) in patients with nonischemic dilated cardiomyopathy
can be challenging because of the complexity of underlying substrates. We sought to determine the long-term outcomes
of endocardial and adjuvant epicardial CA in nonischemic dilated cardiomyopathy.
Methods and Results—We examined 282 consecutive patients (aged 59±15 years, 80% males) with nonischemic dilated
cardiomyopathy who underwent CA. Ablation was guided by activation/entrainment mapping for tolerated VT and
pacemapping/targeting of abnormal electrograms for unmappable VT. Adjuvant epicardial ablation was performed for
recurrent VT or persistent inducibility after endocardial–only ablation. Epicardial ablation was performed in 90 (32%)
patients. Before ablation, patients failed a median of 2 antiarrhythmic drugs), including amiodarone, in 166 (59%)
patients. The median follow-up after the last procedure was 48 (19–67) months. Overall, VT-free survival was 69% at
60-month follow-up. Transplant-free survival was 76% and 68% at 60- and 120-month follow-up, respectively. Among
the 58 (21%) patients with VT recurrence, CA still resulted in a significant reduction of VT burden, with 31 (53%)
patients having only isolated (1–3) VT episodes in 12 (4–35) months after the procedure. At the last follow-up, 128 (45%)
patients were only on β-blockers or no treatment, 41 (15%) were on sotalol or class I antiarrhythmic drugs, and 62 (22%)
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were on amiodarone.
Conclusions—In patients with nonischemic dilated cardiomyopathy and VT, endocardial and adjuvant epicardial CA is
effective in achieving long-term VT freedom in 69% of cases, with a substantial improvement in VT burden in many of
the remaining patients. (Circ Arrhythm Electrophysiol. 2016;9:e004328. DOI: 10.1161/CIRCEP.116.004328.)
Key Words: antiarrhythmic drug ◼ catheter ablation ◼ dilated cardiomyopathy
◼ electroanatomic mapping ◼ ventricular tachycardia
1
2 Muser et al Long-Term Outcome of VT Ablation in NIDCM
Figure 1. Examples of typical distribution of endocardial ablation linear lesions across abnormal left ventricle to valve annulus in a patient
with multiple unmappable ventricular tachycardias (VTs). Linear lesions transecting the putative VT isthmuses were placed through the
sites of best pace maps with long stimulus to QRS and were anchored to the valve annulus.
mV) in the presence of no or minimal bipolar (<1.5 mV) electrogram and small-vessel coronary vasculature (ie, vessels that cannot be direct-
abnormality; and (4) there was failure of endocardial ablation (either ly appreciated by coronary angiogram) on the low-voltage region, the
early VT recurrence or persistent inducibility of clinical VT). Access to contiguous low-voltage electrograms had to demonstrate not only low
the pericardial space was obtained using the percutaneous subxiphoid amplitude but also discrete late potentials (recorded after the QRS of the
approach described by Sosa et al.17 An 8F sheath (or deflectable sheath) surface ECG) and demonstrate broad multicomponent or split signals.
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was introduced into the pericardial space, and the mapping/ablation Signals >1.0 mV that also demonstrated abnormal, multicomponent,
catheter was advanced through the sheath. Detailed voltage mapping split or late potentials were also tagged and if adjacent to confluent areas
was performed with a surface and color fill threshold maintained at 15 of low voltage typically included in substrate-based ablation targets.
mm. The reference value for defining abnormal electrograms in the
epicardium was <1.0 mV, as previously reported.4 Dense scar was also Catheter Ablation
arbitrarily defined as <0.5 mV for display purposes for the epicardial The primary ablation end point was elimination of the clinical VT(s)
electroanatomic maps. To further limit the influence of epicardial fat and all mappable nonclinical VT(s). All induced VT(s) with a CL
Figure 2. Example of endocardial (A) and epicardial (B and C) substrate modification in a patient with minimal endocardial substrate.
Black dots (B and C) indicate abnormal electrograms. Coronary angiography was performed to confirm safe distance of the ablation sites
on the epicardium from the major coronary vessels.
4 Muser et al Long-Term Outcome of VT Ablation in NIDCM
>250 ms were also considered potentially relevant and routinely Table 1. Baseline Characteristics of the Study Sample
targeted for ablation. For hemodynamically tolerated VT(s), entrain-
ment mapping was performed at sites showing diastolic activity to Age, y 59±15
identify critical sites of the VT re-entrant circuit. Sites with con- Male sex, n (%) 227 (80)
cealed QRS fusion and return cycle within 30 ms of the VT CL with
matching stimulus-QRS and electrogram-QRS intervals or where VT Clinical characteristics
terminated during pacing without global capture were considered Family history of cardiomyopathy or sudden cardiac
critical.18,19 Radiofrequency energy was delivered at these sites (see 34 (12)
death, n (%)
below). For hemodynamically unstable VTs, substrate modification
was performed, with cluster/linear lesions targeting sites identified Hypertension, n (%) 95 (34)
by pace mapping, as well as abnormal electrograms.15 The putative Diabetes mellitus, n (%) 36 (13)
VT site of origin was defined using pace mapping to reproduce the
VT QRS complex and to identify sites with a long stimulus to QRS Hyperlipidemia, n (%) 65 (23)
interval. Limited activation and entrainment information were used Chronic kidney disease, n (%) 57 (20)
to corroborate the pace map information when possible. Typically,
lesions were delivered through the sites of best pace map with long Chronic obstructive pulmonary disease, n (%) 26 (9)
stimulus to QRS (>30 ms). The ablation lesions were extended to Obstructive sleep apnea, n (%) 24 (8)
target markedly abnormal fractionated split and late potentials and,
for endocardial ablation, were typically anchored to the valve annuli Previous cardiac arrest, n (%) 26 (9)
(Figure 1). Specific emphasis was given to target abnormal potentials History of unexplained syncope, n (%) 64 (22)
recorded within a 2- to 3-cm radius of the region of interest, defined
by entrainment mapping or pace mapping techniques, with the end History of atrial fibrillation, n (%) 66 (23)
point of signal modification or elimination (Figure 2). Epicardial NYHA class III/IV, n (%) 84 (30)
radiofrequency lesions always avoided large coronary vessels by at
least 1 cm based on cine angiography. If inducibility of monomorphic ICD, n (%) 240 (85)
VT persisted after ablation, residual inducible VTs were remapped Clinical presentation with VT storm, n (%) 71 (25)
and targeted using the techniques described earlier.
Radiofrequency energy application with the 4-mm standard cath- Transthoracic echocardiography
eter was set at 50 W and 55°. Open-irrigated ablation targeted a maxi- LVEF, % 36±13
mum temperature of 42° and a maximum impedance drop of 12 to
15 Ohms with power 20 to 50 W. Closed-irrigated ablation was set LVEF ≤ 35%, n (%) 137 (49)
to deliver 20 to 50 W, targeting a maximum temperature of 45° and Moderate to severe right ventricular dysfunction, n (%) 33 (12)
maximum impedance drop of 12 to 15 Ohms. Lesion duration was
typically set for 60 to 90 seconds but was further increased to ≥3 Moderate to severe diastolic dysfunction, n (%) 47 (17)
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among the same patients were compared using paired-sample para- stimulation or NIPS in the remaining 34/102 (33%) patients.
metric (paired t test) or nonparametric (paired Wilcoxon signed-rank A total of 172/442 (38%) procedures were performed under
test) tests. Categorical variables were compared using chi-square test
general anesthesia. In 21 (5%) procedures, mechanical
or Fisher exact test when appropriate. Survival curves were generated
by the Kaplan–Meier method and compared with the log-rank test. hemodynamic support was used because of periprocedural
Univariable and multivariable Cox proportional hazards analysis (us- hemodynamic instability (mostly after year 2010). The
ing the forward stepwise model selection procedure) was used to test majority of the procedures were performed via a retrograde
the association between the outcome event and baseline covariates. transaortic approach; an antegrade transseptal approach was
VT recurrence over follow-up was included as a time-dependent co- used in 31 (7%) cases.
variate. Only variables with P value <0.1 at univariable analysis were
entered as covariates in the multivariable model. Two-tailed tests During the procedure, a median number of 2 (1–4) dif-
were considered statistically significant at the 0.05 level. Analyses ferent VTs were induced with a mean CL of 386±98 ms. At
were performed using IBM SPSS version 23.0 software (SPSS Inc, least one hemodynamically unstable VT was induced in 239
Chicago, IL). (85%) patients. All patients underwent endocardial mapping
and ablation. The interventricular septum was identified as a
Results source of VT and targeted for ablation in 84 (30%) patients.
In 28 (10%) cases, the coronary cusp region was targeted for
Study Population
ablation. Epicardial mapping was performed in 168 (38%)
Baseline characteristics of the study population are summarized procedures (122 patients) and epicardial ablation in 118 (27%)
in Table 1. Two-hundred and eighty-two consecutive patients procedures (90 patients).
with NIDCM (age 59±15 years, 80% males) underwent CA At the end of the last procedure, a total of 262 (92%)
after failure of 2 (1–2) AADs. Forty-five (16%) patients were patients underwent programmed ventricular stimulation; in
referred after a previous endocardial CA attempt at an outside 20 cases, this was not performed because of unstable patient
Institution. At baseline, 166 (59%) patients were receiving ami- conditions. The clinical VT was still inducible in 32 (12%)
odarone therapy (intravenous infusion only in 29 cases). The patients, and 46 (18%) patients had at least one nonclinical
mean preprocedure daily oral amiodarone dose was 290±148 VT still inducible. A total of 101 (36%) patients underwent
mg. In 37 (13%) patients, sotalol or at least one class I AAD had NIPS from the ICD a median of 3 (2–4) days after the last
been attempted before ablation (Figure 3). In 71 (25%) patients, procedure: the clinical VT was not inducible in 84/101 (83%)
the clinical presentation was VT storm, defined as ≥3 appropri- patients while noninducibility of any VT was achieved in
ate ICD interventions in 24 hours or incessant VT. 63/101 (62%) patients.
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Table 2. Procedural Characteristics and Acute Procedural without consequence. Two patients had an occlusion of a
Outcomes (442 Procedures Among 282 Patients) small coronary artery branch during epicardial ablation (both
Multiple procedures, n (%) 102 (36)
small obtuse-marginal branches). Finally, one patient had
phrenic nerve injury during epicardial ablation with transient
Single ablation, n (%) 180 (64) hemi-diaphragm paralysis.
2 ablations, n (%) 66 (23)
3 or more ablations, n (%) 36 (13) Long-Term Outcomes
Indication for repeat ablation among 102 patients with multiple procedures
Events occurring during the follow-up period are summarized
in Table 3. After a median follow-up of 48 (19–67) months, 24
VT recurrence, n (%) 68/102 (67) patients underwent heart transplantation and 43 died. Overall
Time between repeated procedures, days 161 (39–569) transplant-free survival was 76% and 68% at 60- and 120-
Persistent inducibility at the end of the procedure/NIPS month follow-up, respectively (Figure 4). Cumulative VT-free
34/102 (33) survival after the last procedure was 69% at 60-month follow-
or early recurrence of VT within 48 h, n (%)
up (Figure 5). Among the 58 patients with VT recurrences,
Time between repeated procedures, days 4 (2–5)
a significant reduction of VT burden was observed, with
Procedural data 31/58 (53%) patients having only isolated (≤3 VT) episodes
General anesthesia, n (%) 172/442 (38) occurring during an average of 12 months after the procedure
Left ventricular hemodynamic support during the (Figure 5).
21/442 (5) At the last follow-up, 128 (45%) patients were only on
procedure, n (%)
β-blockers or no treatment, 41 (15%) were on sotalol or class
Transseptal access to the left ventricle, n (%) 31/442 (7)
I AADs, and 62 (22%) were on amiodarone (Figure 3). The
Total procedural time, hours 8 (6–10) daily dose of amiodarone at last follow-up was 247±103 mg.
Fluoroscopy time, min 60 (47–94) Table 4 shows the results of the univariable and multivari-
Radiofrequency time, min 38 (24–61)
able Cox proportional hazards analysis of correlates of events
during follow-up. In multivariable analysis, LVEF≤35% (haz-
Mapping and ablation ard ratio [HR] 2.60, 95% confidence interval [CI] 1.06–6.38;
Epicardial mapping, n (%) 168/442 (38) P=0.04) and inducibility of any VT with CL>250 ms at post-
Epicardial ablation, n (%) 118/442 (27) procedural NIPS (HR 3.53, 95% CI 1.42–8.80; P=0.007) were
the only variables independently associated with VT recur-
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Study Limitations
This was a single-center observational study summarizing a
15-year experience with CA in patients with NIDCM. The out-
comes we reported reflect the experience of our tertiary referral
center and may not be generalized to lower volume Institutions
with less experience with endocardial and epicardial VT CA.
The choice for the specific ablation approach (ie, endocardial-
only versus endocardial–epicardial ablation) and the additional
therapeutic strategies implemented during follow-up (including
repeat CA and continuation/discontinuation of AADs, such as
amiodarone) was not randomized, and as expected, the acute
ablation end points evolved over the multiyear study period.
However, given the single center nature of the study, the ablation
approaches and protocols adopted were uniform. In this regard,
the decision to perform endocardial–epicardial mapping and
ablation was driven by 4 criteria, namely, (1) the 12-lead ECG of
the VT suggested an epicardial origin; (2) evidence of epicardial
substrate on imaging studies (eg, magnetic resonance, intracar-
Figure 5. Kaplan–Meier survival curves showing survival free diac echocardiography); (3) endocardial unipolar electrogram
from any sustained ventricular tachycardia (VT) after the last abnormality (<8.3 mV) in the presence of no or minimal bipolar
procedure in the whole population (A) and stratified according to (<1.5 mV) electrogram abnormality; and (4) failure of endo-
left ventricular ejection fraction (LVEF; B). Catheter ablation still
resulted in a significant reduction of VT burden among patients cardial ablation (VT recurrence or persistent inducibility of VT
experiencing VT recurrence (C). after endocardial ablation). Patients, who underwent endocar-
dial-only ablation, were enrolled earlier in the experience and,
at follow-up, confirming postprocedure NIPS as an important as a result, also had a longer follow-up, which may potentially
prognostic tool to identify patients with not only ischemic act as a bias. Furthermore, the year of enrollment may also have
cardiomyopathy but also NIDCM who may need additional influenced the decision to perform epicardial ablation because
9 Muser et al Long-Term Outcome of VT Ablation in NIDCM
Table 4. Univariable and Multivariable Cox Proportional Hazards Analysis of Baseline Covariates in Relation to Outcome Events
VT Recurrence Death/Heart Transplant
Univariable Multivariable Univariable Multivariable
HR (95% CI) P Value HR (95% CI) P Value HR (95% CI) P Value HR (95% CI) P Value
Male 1.91 (0.86–4.21) 0.111 1.60 (0.79–3.23) 0.192
Age 1.02 (1.00–1.04) 0.111 1.02 (1.00–1.04) 0.044 … …
Family history of
sudden cardiac death/ 1.36 (0.66–2.77) 0.402 1.13 (0.54–2.38) 0.742
cardiomyopathy
Diabetes mellitus 1.21 (0.52–2.83) 0.655 2.33 (1.29–4.23) 0.005 … …
Hypertension
0.73 (0.42–1.25) 0.250 1.99 (1.23–3.25) 0.006 … …
our threshold for proceeding with an epicardial ablation became The majority of patients have complete VT control, and
lower starting in year 2004 (only 20% of the epicardial ablations most of the remaining patients have a substantial improve-
were performed before 2004 in our series). Given the observa- ment in VT burden with limited need for AADs. However,
tional nature of the study, we could not fully assess the impact of given the significant burden of associated comorbidities
evolving mapping technologies, including the adoption of uni- and severity of heart failure, up to one third of patients died
polar voltage mapping and multielectrode high-density mapping or required heart transplant over follow-up. Recurrent VT
on the outcomes. However, we did not find a significant interac- was found to be independently associated with increased
tion between year of enrollment and procedural outcomes (Data risk of subsequent death/transplant. Further studies are
Supplement). Finally, our survival analysis shown in Figure 5 necessary to evaluate whether a more aggressive treat-
is referenced to the date of the last procedure, which can only
ment of recurrent VT may translate into a mortality ben-
be determined retrospectively. However, because good arrhyth-
efit in these patients.
mia control frequently requires more than a single procedure
in patients with nonischemic cardiomyopathy and VT, it was
appropriate to establish a reference point regarding outcome that Source of Funding
recognized this frequent requirement. Supported by the Richard T. and Angela Clark Innovation Fund and
the F. Harlan Batrus Research Fund in Cardiac Electrophysiology.
Conclusions
Endocardial with adjuvant epicardial ablation of VT in Disclosures
NIDCM provides good long-term arrhythmia-free survival. None.
10 Muser et al Long-Term Outcome of VT Ablation in NIDCM
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