Original Article

Noninducibility in Postinfarction Ventricular

Tachycardia as an End Point for Ventricular
Tachycardia Ablation and Its Effects on Outcomes
A Meta-Analysis
Hamid Ghanbari, MD, MPH; Kazim Baser, MD; Miki Yokokawa, MD;
William Stevenson, MD; Paolo Della Bella, MD; Pasquale Vergara, MD; Thomas Deneke, MD;
Karl-Heinz Kuck, MD; Hans Kottkamp, MD; She Fei, MD, PhD; Fred Morady, MD;
Frank Bogun, MD

Background—Although ventricular tachycardia (VT) ablation is a widely used therapy for patients with VT, the ideal end
points for this procedure are not well defined. We performed a meta-analysis of the published literature to assess the
predictive value of noninducibility of postinfarction VT for long-term outcomes after VT ablation.
Methods and Results—We performed a systematic review of MEDLINE (1950–2013), EMBASE (1988–2013), the Cochrane
Controlled Trials Register (Fourth Quarter, 2012), and reports presented at scientific meetings (1994–2013). Randomized
controlled trials, case–control, and cohort studies of VT ablation were included. Outcomes reported in eligible studies
were freedom from VT/ventricular fibrillation and all-cause mortality. Of the 3895 studies evaluated, we identified 8
cohort studies enrolling 928 patients for the meta-analysis. Noninducibility after VT ablation was associated with a
significant increase in arrhythmia-free survival compared with partial success (odds ratio, 0.49; 95% confidence interval,
0.29–0.84; P=0.009) or failed ablation procedure (odds ratio, 0.10; 95% confidence interval, 0.06–0.18; P<0.001). There
was also a significant reduction in all-cause mortality if patients were noninducible after VT ablation compared with
patients with partial success (odds ratio, 0.59; 95% confidence interval, 0.36–0.98; P=0.04) or failed ablation (odds ratio,
0.32; 95% confidence interval, 0.10–0.99; P=0.049).
Conclusions—Noninducibility of VT after VT ablation is associated with improved arrhythmia-free survival and all-cause
mortality.  (Circ Arrhythm Electrophysiol. 2014;7:677-683.)
Key Words: meta-analysis ◼ tachycardia, ventricular

S everal studies have demonstrated the efficacy of radiofre-

quency catheter ablation as adjunctive therapy in selected
patients with recurrent, drug-resistant ventricular tachycar-
dia (VT).1,2 Despite major advances in the field, this therapy
remains technically challenging and time-consuming.3,4
Different ablation strategies have been proposed, and their
outcomes have been different across clinical trials.5–8 Several
studies have demonstrated that patients in whom VT cannot be
induced at the conclusion of an ablation have a favorable out-
come.9,10 However, these studies have been limited because of
the small number of patients, heterogeneous population, and
lack of long-term follow-up. Therefore, the ideal end point
of VT ablation in patients with prior infarction is unclear.
To answer this important clinical question, we evaluated the
outcomes of patients with prior myocardial infarction who
were noninducible after VT ablation compared with those
who remained inducible at the end of the procedure through a
meta-analysis of studies published in the literature.
Editorial see p 567
Clinical Perspective on p 683
Methods
Search Strategy
We searched MEDLINE (1950–2013), EMBASE (1988–2013), the
Cochrane Controlled Trials Register (2013), and reports presented
at scientific meetings (1994–2013). We performed searches using

Received August 5, 2013; accepted May 1, 2014.

From the Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor (H.G., K.B., M.Y., F.M., F.B.); Department of
Internal Medicine, Cardiovascular Division, Brigham and Women Hospital, Boston, MA (W.S.); Arrhythmia Unit and Electrophysiology Laboratories, San
Raffaele Hospital, Milano, Italy (P.D.B., P.V.); Klinik für Kardiologie II, Herz- und Gefäß-Klinik GmbH, Bad Neustadt, Germany (T.D.); Hanseatisches
Herzzentrum, Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K.); Department of Electrophysiology, Klinik Hirslanden, Zürich, Switzerland (H.K.);
and Department of Internal Medicine, Division of Cardiology, Peking University Third Hospital, Beijing, China (S.F.).
Guest Editor for this article was Gerhard Hindricks, MD.
The Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.113.001404/-/DC1.
Correspondence to Frank Bogun, MD, Cardiovascular Center, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5869. E-mail
fbogun@umich.edu
© 2014 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org DOI: 10.1161/CIRCEP.113.001404

677
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678  Circ Arrhythm Electrophysiol  August 2014
Web-based search engine OVID with explode option for each subject
term and the option AND for combining keywords. The MEDLINE
was searched from January 1950 to May 2013. The MeSH terms
included VT and ablation. We also used a previously developed
MEDLINE search strategy to retrieve the strongest scientific studies
of treatment by conducting a sensitive search.11 The EMBASE data-
base was searched from January 1988 to 2013 with keywords includ-
ing VT and catheter ablation. The Cochrane Controlled Trials Register
was searched with a similar approach. All searches were performed in
May 2013. We conducted additional searches using 11 author names
frequently cited in narrative reviews of VT ablation, as well as modified
versions of the Cochrane Optimal Search Strategy.12 The bibliographies
of 10 most recent narrative review articles were also hand-searched. To
reduce bias, we restricted our searches to articles reported in English
language.13 Because the meta-analysis was an analysis of prior pub-
lished studies, an institutional review board approval is not applicable.
Study Selection
Randomized controlled trials, case–control, or cohort studies evaluat-
ing ablation for treatment of VT were eligible. Case–control and co-
hort studies were defined according to the STROBE (STrengthening
the Reporting of OBservational studies in Epidemiology) statement.
The study followed the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses statement.
Studies were included if the outcome was reported depending on
inducibility of VT after completion of the ablation procedure. The
outcomes of interest were recurrence of VT/ventricular fibrilla-
tion (VF) and all-cause mortality. Authors of relevant studies were
contacted to obtain these data if not reported in the original article.
Additional information from 4 studies was provided by the authors
and included in the article. We included only studies with a postab-
lation programmed ventricular stimulation protocol. A limitation of
programmed stimulation is the lack of a universally agreed protocol
for VT induction.14,15 This analysis, therefore, was limited to studies
using a generally accepted stimulation protocol with ≥2 basic drive
cycle lengths with ≤3 extrastimuli at 2 ventricular sites.4 The length
and adequacy of follow-up in all the included trials were thought to
be sufficient to allow the outcomes of interest to occur within the
follow-up period.
Data Abstraction
Two independent reviewers (H.G. and S.F.) evaluated the studies for
inclusion into the meta-analysis. A third blinded reviewer (F.B.) re-
solved disagreements between reviewers. Abstracted data included
eligibility criteria, baseline characteristics, duration of follow-up,
cause of heart failure, procedural complications, and number of pa-
tients in the trial.
Definitions
Complete success was defined as elimination of all inducible VTs at
the conclusion of the procedure. Partial success was defined as elimi-
nation of all clinical VTs with ≥1 nonclinical VT inducible at the end
of the procedure. The procedure was labeled as unsuccessful if any
clinical VT still was inducible at the end of the procedure.
Quality Assessment
We used the Newcastle-Ottawa Scale to describe the quality of the
studies included in the meta-analysis. The items assessed for cohort
studies were as follows: (1) representativeness of the exposed cohort,
(2) selection of the nonexposed cohort, (3) ascertainment of expo-
sure, (4) outcome of interest not present at the onset of the study, (5)
comparability of cohorts on the basis of the design or the analysis,
(6) assessment of outcome, (7) length of follow-up long enough for
outcomes to occur, and (8) adequacy of follow up of cohorts. One
or 2 stars were assigned and are displayed in Table I in the Data
Supplement summarizing risk of bias.
We used the Grades of Recommendations, Assessment,
Development, and Evaluation system to evaluate the quality of the
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evidence for outcomes reported in this review. Because only ob-
servational studies were available, the body of evidence was as-
signed according to the Grades of Recommendations, Assessment,
Development, and Evaluation system as low quality in the first place.16
For most outcomes, the quality of evidence was further downgraded
to very low quality. The summary of findings and evidence profile
were created using the Grades of Recommendations, Assessment,
Development, and Evaluation software.
Statistical Analysis
Odds ratio (OR) was chosen as the principal measure of effect.
The ORs from each included study were pooled using fixed- and
random-effects models that used weighting based on inverse vari-
ance calculated according to DerSimonian and Laird.17 The Q test
and I2 index were used to check for quantitative heterogeneity,18 with
P<0.05 deemed statistically significant. Where no significant statisti-
cal heterogeneity was identified, the fixed-effects estimate was used
preferentially as the summary measure. Sensitivity analyses were
performed to assess the contribution of each study to the pooled es-
timate by excluding individual trials one at a time and recalculating
the pooled OR estimates for the remaining studies. Publication bias
was assessed graphically using a funnel plot and mathematically
using an adjusted rank correlation test, according to the method of
Begg and Mazumdar.19 Sensitivity analyses were performed to assess
the importance of different statistical models. There were no differ-
ences in the general direction of outcomes when using the fixed- and
random-effects models. All statistical analyses were performed with
Comprehensive Meta-Analysis 2.0.
Results
Qualitative Analysis
All the trials included in this analysis were observational
cohort studies. Baseline characteristics of the patients enrolled
in these trials, types of cardiomyopathy, and follow-up and
ablation strategies are summarized in the Table. There were
sufficient similarities in these trials warranting their inclu-
sion in this analysis. We have summarized the qualitative dif-
ferences between groups using the Newcastle-Ottawa Scale
in Table I in the Data Supplement. We assessed the overall
quality of evidence using the Grades of Recommendations,
Assessment, Development, and Evaluation criteria, and the
results are provided in Figures I to III in the Data Supplement.
Quantitative Analysis
Of 3895 studies evaluated, we identified 8 cohort studies
enrolling 928 patients for the meta-analysis (Figure IV in
the Data Supplement).20–27 Additional information from
4 articles was provided by the authors and included in
the final analysis.20,23,26,27 The Q2 test score was 10.01, and
the I2 index was 50.08 indicating moderate heterogeneity
(P=0.07). There was no evidence of significant publication
bias according to Begg and Mazumdar rank correlation test
(τ=−0.13; P=0.71). We performed several sensitivity analy-
ses to assess the effect of each study on the pooled effect
estimate. Exclusion of no single trial significantly altered the
overall result of our analysis.
Efficacy of VT ablation
Noninducibility of VT was achieved in the majority of the
patients (event rate, 0.59; 95% confidence interval [CI], 0.49–
0.67). Partial success was achieved in a higher number of
 Ghanbari et al   VT Ablation and Outcomes: A Meta-Analysis   679

Table.  Characteristics of the Included Studies

No. of Patients
No. of VT/VF With No EPS
No. of Follow-Up Time, Patients Lost to Episodes Before at the End of
Study Age, y Patients, n mo Follow-Up, n Ejection Fraction Sex (Male) Ablation Ablation
Deneke et al20 66±9 115 Median: 16±10 0 34±13% NA 21.5±40 VT 0
mo episodes in 3 mo
Range: 12–50 mo Range: 4–220 mo
Reddy et al21 66±7.9 11 Mean: 13.1±1.9 0 31±8% NA NA 0
mo Range: 20%–40%
Range: 12–16 mo
Kim et al22 67±8 21 Mean: 13.2±5.0 None 31.7±7.5 20/21 NA 0
Range: 5–21 mo
Stevenson et al23 Median: 68 231 6 mo for the 6 Median: 25% 206/231 Median of 11 19 (8%)
assessment 25th to 75th episodes of VT in
of recurrent percentile: the preceding 6
arrhythmias, 12 20%–35% months
mo for death 25th to75th
percentile: 5–32
mo
Della Bella et al24 67±6 137 Median: 36 mo None 36.3±7.6% 91/137 NA 0
Interquartile (complete
range: 18–60 mo success)
34.6±7.1%
(partial or no
success)
Deneke et al25 62±10 25 10±4 mo None 37±12 NA NA 0
Yokokawa et al26 67±10 98 Mean: 35±23 mo 0 Mean: 27±13% 88/98 NA 3 (3%)
Range: 1–89 mo
Della Bella et al27 62.1±14 Total: 528 Median: 26 mo 47 38.5±13 473/528 151 (28.6%) with Overall: 46/528
Ischemic: 290 Interquartile electric storm (8.7%)
range: 13–46 mo Ischemic: 22/290
(7.5%)
EPS indicates programmed ventricular stimulation; VF, ventricular fibrillation; and VT, ventricular tachycardia.

patients (event rate, 0.27; 95% CI, 0.20–0.36) compared with
failed ablation (event rate, 0.10; 95% CI, 0.06–0.17).
Noninducibility and Recurrence of VT/VF
There were a significant number of patients who had recurrence
of VT after the ablation procedure, despite being noninducible
at the conclusion of the procedure (range, 11%–37%). However
a larger number of patients who had a failed ablation had recur-
rence of VT (range, 76%–100%). There were also a significant
number of patients with partial success who had recurrence of
VT after ablation (range, 27%–61%). Patients who were ren-
dered noninducible at the conclusion of the index VT ablation
procedure were less likely to have recurrence of VT/VF during
follow-up compared with patients with a partially successful
(OR, 0.49; 95% CI, 0.29–0.84; P=0.009; Figure 1) or a failed
ablation procedure (OR, 0.10; 95% CI, 0.06–0.18; P<0.001;
Figure 2). Patients with partial success were less likely to have
recurrence of VT/VF compared with those with failed ablation
(OR, 0.24; 95% CI, 0.13–0.45; P<0.001; Figure 3).

Figure 1. Noninducible vs partial success and ventricular tachycardia (VT) recurrence. The 95% confidence intervals (CIs; error bars),
overall effect (diamonds), and effect for each study (squares) are displayed; overall effect and effect for each study represent the width of
the CI. Two studies21 did not report VT/ventricular fibrillation (VF) events, and 1 study25 reported VT/VF events in every patient; therefore,
they were not included in the overall analysis.

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680  Circ Arrhythm Electrophysiol  August 2014

Figure 2. Noninducible vs failed ablation and ventricular tachycardia (VT) recurrence. One study26 did not report VT/ventricular fibrillation
(VF) events, and 1 study25 reported VT/VF events in every patient; therefore, they were not included in the overall analysis. CI indicates
confidence interval.

Noninducibility and Mortality However, in the absence such a trial, a meta-analysis is an

Patients who were noninducible at the end of the ablation pro-
cedure had a lower risk of mortality compared with those with
a partially successful procedure (OR, 0.59; 95% CI, 0.36–0.98;
P=0.04; Figure 4) or failed ablation (OR, 0.32; 95% CI, 0.10–
0.99; P=0.049; Figure 5). There was no difference in mortality
in patients in whom only the clinical VT could be eliminated
compared with the patient group in whom the ablation failed
(OR, 0.37; 95% CI, 0.11–1.22; P=0.10; Figure 6).
Discussion
Main Findings
This meta-analysis demonstrates that lack of inducibility of
any VT after ablation of postinfarction VT is associated with
longer longevity and lower VT/VF recurrence and, therefore,
is a reasonable end point for VT ablation.
Lack of VT Inducibility as an End point for
VT Ablation
The traditional end point of VT ablation has been noninduc-
ibility of VT using programmed ventricular stimulation.4 The
use of this end point in determining the success of VT abla-
tion has been called into question because of its many limita-
tions.28 Several studies have attempted to clarify the value of
programmed stimulation to predict outcome after an ablation
procedure, but they have been limited by a small number of
patients with short-term follow-up. A randomized clinical trial
would be the most appropriate way to answer this question.
important tool in helping clinicians determine the value of
noninducibility on the outcomes of VT ablation procedures.
This meta-analysis demonstrated that noninducibility of VT
was associated with a significant reduction in both mortality
and recurrence of VT/VF events. It is possible, though, that
the patients who remain noninducible after VT ablation may
represent a healthier population with a more favorable out-
come. Therefore, lack of inducibility may represent a health-
ier substrate rather than an ideal outcome after VT ablation.
Limitations of Programmed Stimulation as an End
Point for VT Ablation
There are several limitations when performing programmed
stimulation after VT ablation procedures. The lack of inducibil-
ity of VTs up-front and the potential suppression of VTs with
antiarrhythmics such as amiodarone make it difficult to be cer-
tain that all of the VTs in a given patient have been targeted and
eliminated during the ablation procedure. Not all VTs are repro-
ducibly inducible, and the lack of reproducibility of VT induc-
tion may limit the predictive value of noninducibility at the end
of the ablation procedure. Furthermore, programmed stimulation
at the conclusion of a long ablation procedure may not be safe
in an unstable patient and, therefore, may need to be deferred.
The substrate responsible for initiation and maintenance of VT
in patients with ischemic heart disease is prone to changes over
time. A changing substrate may curtail the prediction of future
events based on programmed stimulation at one point in time.
Despite these limitations, the predictive value of programmed
stimulation cannot be ignored, and to assure the best possible

Figure 3. Partial success vs failed ablation and ventricular tachycardia (VT) recurrence. One study26 did not report VT/ventricular fibrillation
(VF) events, and 1 study25 reported VT/VF events in every patient; therefore, they were not included in the overall analysis. CI indicates
confidence interval.

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 Ghanbari et al   VT Ablation and Outcomes: A Meta-Analysis   681

Figure 4. Noninducible vs partial success and mortality. Two studies21,25 did not report mortality events; therefore, they were not included
in the overall analysis. CI indicates confidence interval.

outcome of a VT ablation procedure, programmed stimulation
should strongly be considered at the conclusion of the ablation
procedure. A recent report in which ablation of the entire scar
was performed supports this consideration. A strategy target-
ing and ablating the entire low-voltage area demonstrated a
significantly improved outcome compared with patients in
whom arrhythmias were specifically targeted, provided that the
patients were rendered completely noninducible.29 The former
study confirms the value of programmed stimulation as an end
point when different ablation strategies are compared.
In patients in whom no VT can be induced at baseline, a
different ablation strategy needs to be pursued. The predictive
value of abolition of late potentials as a procedural end point
has been evaluated and found to be beneficial especially in
patients without inducible VTs at baseline.30
Ablation of the Clinical VT and Outcomes
Our analysis demonstrated only a trend toward reduced mor-
tality in patients in whom VT remained inducible after abla-
tion if at least the clinical VTs could be eliminated. There was,
however, a significant reduction of VT recurrence if this end
point was achieved. This information is important because
common practice considers targeting the clinical VT as an
acceptable strategy,4 and based on this analysis complete elim-
ination of VT was associated with significantly lower mortal-
ity and VT recurrence compared with partial success and may,
therefore, be considered a preferred end point when feasible.
A smaller study including both ischemic and nonischemic
patients also demonstrated similar results.10 However, inducibil-
ity of multiple VTs before the procedure and failure to eliminate
all VTs may just identify a sicker patient population with larger
scar burden. Therefore, failure to eliminate VTs may identify a
more diseased patient population with a worse prognosis and
higher likelihood of future VT/VF recurrence. However, fail-
ure to eliminate VT after ablation in high-risk patients has been
associated with an increase in cardiac mortality compared with
high-risk patients in whom VT could be eliminated.27 Therefore,
it is possible that effective ablation alone confers a more favor-
able impact on outcomes, particularly in high-risk patients.
Search for an Optimal Ablation End Point
Despite the predictive value of programmed stimulation on
outcomes, patients still have VT recurrences even if they are
completely noninducible at the end of the ablation procedure.
The use of noninvasive programmed stimulation a few days
after VT ablation has been described to help improve assess-
ment of outcomes after VT ablation.5,31 Edema formation may
prohibit VT inducibility immediately after ablation as opposed
to inducibility several days later after some of the edema has
resolved. This strategy may not affect intraprocedural end
points during the ablation procedure but may help to increase
the predictive value of noninducible patients. Elimination of
abnormal electrograms has been demonstrated to be beneficial
in reducing recurrences and may be used in situations where
not all VTs can be induced to prevent recurrences.32
Limitations
This meta-analysis is limited by the studies included in the
analysis. All of the studies were observational studies, and

Figure 5. Noninducible vs failed ablation and mortality. Three studies21,25,26 did not report mortality events; therefore, they were not
included in the overall analysis. CI indicates confidence interval.

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682  Circ Arrhythm Electrophysiol  August 2014
Figure 6. Partial success vs failed ablation and mortality. Four studies22,25,26 did not report mortality events; therefore, they were not
included in the overall analysis. CI indicates confidence interval.
therefore they are susceptible to selection bias. There were
significant differences in the patients included and the strat-
egy used when performing VT ablations. Although the overall
strategy was to target all inducible VTs, only 1 study indicated
ablation of all clinically relevant VTs as a predetermined end
point.23 Table II in the Data Supplement indicates the specific
protocols and catheters used in the analyzed studies.
Another important limitation is the definition of the clinical
VT. The definition used in the selected studies is not uniform
and is not based on the 12-lead ECG in all studies. Because
12-lead ECGs are not available for all patients, VT electro-
gram morphology from implantable cardioverter defibrillators
can be used instead with similar accuracy and have been found
to be helpful in identifying the clinical VT.5 This definition
was used by only one, but not all studies.26
Although the stimulation protocol was not uniform, all
studies included used stimulation from ≥2 ventricular sites
with ≤3 extrastimuli. The details are indicated in Table II in
the Data Supplement. Left ventricular stimulation was not
uniformly used, yet the incremental benefit of left ventricular
stimulation compared with stimulation from 2 right ventricu-
lar sites is rather small.14
None of the included studies accounted for baseline differ-
ences when comparing the results of patients who remained
inducible compared with those without inducible VT at the
end of the ablation procedure. These differences may influ-
ence the short-term and long-term outcomes of the index VT
ablation procedure. The ideal away to overcome the differ-
ences in baseline characteristics and follow-up would be to
conduct a meta-analysis using individual patient data for time-
to-event analysis. However, in the absence of such data, our
analysis represents the best available evaluation of effects of
noninducibility on outcomes after VT ablation. Unfortunately,
because individual patient data were not available for analysis,
we were not able to analyze data separately from a minority of
patients in whom programmed stimulation was not performed
at the conclusion of the ablation procedure. Furthermore, 1
study27 included a minority of noninducible patients at the
onset of the procedure, and a separate analysis excluding these
patients could not be performed. Exclusion of this study, how-
ever, did not change the overall results of this analysis.
Conclusions
Noninducibility of any VT may be a preferred end point of VT
ablation in patients with postinfarction VT. However, although
this may be the most preferred end point, this should not
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compromise patient stability, which may be a concern in some
patients with advanced disease. Whether noninducibility is an
independent marker for improved long-term outcome remains
to be determined. Additional studies are needed to evaluate the
effect of different ablation strategies and end points to opti-
mize the outcomes of patients undergoing VT ablation.
Sources of Funding
Dr Bogun has received a grant from the Leducq foundation. Dr
Ghanbari has received a grant from the Birkhill foundation.
Disclosures
Dr Bogun participated in a catheter study by Biosense Webster.
Dr Stevenson is coholder of a patent for needle ablation that is
consigned to Brigham and Women’s Hospital, Dr Della Bella
has received consulting fees from St Jude Medical and Biosense
Webster and research funding from Biosense Webster, St Jude
Medical, and Biotronik. Dr Kuck has research contracts and
grants from Biosense Webster, Medtronic, St. Jude Medical,
and Boston Scientific and has consulted for St. Jude Medical,
Stereotaxis, and Edwards Lifesciences. Dr Ghanbari has received
research funding from Biotronik and St Jude Medical and has
received lecturing honoraria from Biotronik. The other authors
report no conflicts.
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CLINICAL PERSPECTIVE
Postinfarction ventricular tachycardia (VT) can result in substantial morbidity and mortality. VT can be treated with cath-
eter ablation; however, the end point of the ablation procedure is unclear. A meta-analysis of the published literature was
performed to assess the predictive value of noninducibility at the end of the ablation procedure. Patients who were rendered
noninducible at the conclusion of the ablation procedure had fewer VT recurrences and had a lower mortality compared with
patients in whom this was not achieved. Patients in whom only the clinical VT could be eliminated had fewer VT recur-
rences, but the mortality was not reduced compared with patients in whom the ablation failed. It remains to be determined,
however, whether noninducibility is an independent marker for improved long-term outcome. Noninducibility of any VT
at the end of an ablation procedure may be the preferred end point and may affect long-term outcomes after VT ablation.
However, it should not compromise patient safety, which may be a concern in patients with advanced disease.

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 SUPPLEMENTAL MATERIAL

Supplemental Table 1: Risk of Bias

Deneke 26 Yokokawa20 Reddy21 Della Bella24 Deneke25 Kim22 Stevenson27 Della Bella23

Representativeness of the exposed cohorta * * * * * * * *

Selection of the non-exposed cohortb * * * * * * * *

Ascertainment of exposurec * 0 * * * * 0 0

Demonstration that the outcome of interest was

* * * * * * * *
not present at start of studyd

Comparability of cohorts on the basis of the

0 0 0 0 0 0 0 0
design or analysise

Assessment of outcomef * * * * * * * *

Long enough follow up for outcomes to occurg * * * * * * * *

Adequacy of follow-up of the cohortsh * * * * * * 0 0

Stars were assigned according to the following for each category

a
truly representative of the average population
b
drawn from the same community as the exposed cohort
c
programmed stimulation at the end of ablation
d
programmed stimulation at the start of the procedure demonstrated clinical and non clinical VT
e
study controls for the most important risk factors, additional star was given for controlling
other risk factors
f
independent blind assessment or through medical records
g
follow-up was long enough for outcomes to occur
h
complete follow up of all subjects accounted or subjects lost to follow up unlikely to introduce
Supplemental Table 2. Ablation and Programmed Stimulation Protocols in the Included Studies

Study EPS protocol Mapping strategy Ablation technology Clinical VT documentation

26
Deneke Up to three extra stimuli. LV programmed Voltage mapping, pace 3.5 mm irrigated-tip ablation 12 lead ECG: 38 patients
stimulation (n=3) mapping catheter ICD VTCL: 77 patients
Reddy21_ Up to three extra stimuli. Voltage mapping, pace 3.5 mm irrigated-tip ablation Not reported
mapping catheter
4 mm tip temperature
controlled ablation catheter
Kim22 Up to three extrastimuli, 2 drive cycle Pace mapping, activation 4 mm tip temperature 12 lead ECG
lengths, 2 RV sites, LV stimulation if clinical mapping, entrainment controlled ablation catheter
VT not inducible from the right ventricle mapping

Stevenson27 Up to three extrastimuli, 2 drive cycle Pace mapping,
lengths, 2 RV sites Double potentials, Late
potential mapping,
entrainment mapping,
voltage mapping
Della Bella24 Up to three extrastimuli, 3 drive cycle Voltage mapping, non
lengths, RV and LV stimulation contact mapping, entrainment
mapping, activation mapping
3.5 mm irrigated-tip ablation
catheter
4 mm tip temperature
controlled ablation catheter
All sustained VTs with a
cycle length within < 20 ms
of a documented spontaneous
VT.
Not reported

Deneke25 Up to three extrastimuli, 2 drive cycle Voltage mapping, Pace 8 mm tip temperature 12 lead ECG: 9 patients
lengths, 2 RV sites mapping controlled ablation catheter ICD VTCL 15 patents
Yokokowa20 Up to four extrastimuli, 2 drive cycle lengths, Pace mapping, late potential 3.5 mm irrigated-tip ablation ICD electrogram morphology
2 RV sites mapping, voltage mapping, catheter 4 and 8 mm tip
entrainment mapping temperature controlled
ablation catheter
Della Bella23 Up to four extrastimuli, 3 drive cycle lengths, Late potential mapping, 3.5 mm irrigated-tip ablation 12 lead ECGs, ICD VTCL
RV and LV stimulation voltage mapping, activation catheter
mapping

Abbreviations: ICD VTCL: Ventricular tachycardia cycle length based on recordings from the implanted cardioverter defibrillator, RV: right ventricular, LV: left
ventricular
Supplemental Figure 1. GRADE evidence profile table for recurrence of VT/VF in patients with partial success compared with failed
ablation

Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Failed Ablation Partial Success

VT/VF recurrence 827 per 1000 533 per 1000 OR 0.24 322 ⊕⊕⊕⊝
1
EP study at the conclusion of VT (382 to 682) (0.13 to 0.45) (8 studies) moderate
ablation
Mortality 245 per 1000 107 per 1000 OR 0.37 319 ⊕⊕⊕⊝
1
(34 to 284) (0.11 to 1.22) (8 studies) moderate

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval)
is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
Supplemental Figure 2. GRADE evidence profile table for recurrence of VT/VF in non-inducible compared with partial success

Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Partial success Non inducibility

VT/VF recurrence 457 per 1000 292 per 1000 OR 0.49 788 ⊕⊕⊕⊝
1
EP study (196 to 414) (0.29 to 0.84) (8 studies) moderate

Mortality 131 per 1000 82 per 1000 OR 0.59 788 ⊕⊕⊕⊝

1
(52 to 129) (0.36 to 0.98) (8 studies) moderate

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence
interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
Supplemental Figure 3. GRADE evidence profile table for recurrence of VT/VF in non-inducible compared with failed ablation

Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Failed Non induciblity

VT/VF recurrence 827 per 1000 323 per 1000 OR 0.10 665 ⊕⊕⊕⊝
1
EP study (222 to 462) (0.06 to 0.18) (8 studies) moderate

Mortality 245 per 1000 94 per 1000 OR 0.32 665 ⊕⊕⊕⊝

1
(31 to 243) (0.1 to 0.99) (8 studies) moderate

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1
No explanation was provided
Supplemental Figure 4. QUOROM diagram of included studies

Potentially relevant articles identified:

(n=3895)

Studies excluded using search

limitations (n=3691)

Citations or abstracts screened for

possible retrieval (n=204)

Studies excluded (n=703)

Reviews (86)
Case Reports (65)
Non ischemic
Cardiomyopathy (24)
Outcome of interest not reported
(18)

Potentially appropriate studies to be

included in the analysis (n=11)

Outcomes of EP study post procedure not

defined (2) EP protocol inadequate (1)

8 studies included in meta-analysis

Noninducibility in Postinfarction Ventricular Tachycardia as an End Point for Ventricular
Tachycardia Ablation and Its Effects on Outcomes: A Meta-Analysis
Hamid Ghanbari, Kazim Baser, Miki Yokokawa, William Stevenson, Paolo Della Bella,
Pasquale Vergara, Thomas Deneke, Karl-Heinz Kuck, Hans Kottkamp, She Fei, Fred Morady
and Frank Bogun

Circ Arrhythm Electrophysiol. 2014;7:677-683; originally published online May 30, 2014;
doi: 10.1161/CIRCEP.113.001404
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