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      Long-Term Outcomes of Radio-Frequency Catheter Ablation on Ventricular Tachycardias Due to Arrhythmogenic Right Ventricular Cardiomyopathy: A Single Center Experience

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          Abstract

          Aims

          To summarize our experience of radiofrequency catheter ablation (RFCA) for recurrent drug-refractory ventricular tachycardias (VTs) due to arrhythmogenic right ventricular cardiomyopathy (ARVC) in our center over the past 11 years and its related factors.

          Methods and Results

          We reviewed 48 adults (mean age 39.9 ± 12.9 years, range: 14 to 65) who met the present ARVC diagnostic criteria and accepted RFCA for VTs from December 2004 to April 2016. The patients received a total of 70 procedures using two ablation approaches, the endocardial approach in 52 RFCAs, and the combined epicardial and endocardial approach (the combined approach) in 18 RFCAs. Kaplan-Meier survival analysis showed that the combined approach achieved better acute procedural success ( p = 0.003) and better long-term outcomes ( p = 0.028) than the endocardial approach. Patients who obtained acute procedural success with non-inducibility had better long-term outcomes ( p < 0.001). COX regression of multivariate analysis showed that procedural success was the only factor that benefited long-term outcome, irrespective of the endocardial or the combined approach ( p = 0.001). The rate of sudden cardiac death (SCD) in patients without procedural success was significantly higher than that in patients with procedural success ( p = 0.005). All patients without implantable cardioverter defibrillator (ICD) implantation who had successful final RFCA survived.

          Conclusions

          The combined approach resulted in better procedural success and long-term VT-free survival compared with the endocardial approach in ARVC patients with recurrent VTs. Acute procedural success with non-inducibility was strongly related to better long-term VT-free survival and reduced SCD, irrespective of whether this was achieved by the endocardial approach or the combined approach.

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          Ablation of ventricular arrhythmias in arrhythmogenic right ventricular dysplasia/cardiomyopathy: arrhythmia-free survival after endo-epicardial substrate based mapping and ablation.

          Javier Sánchez, Luigi Di Lauro, Claudio Tondo … (2011)
          In patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy, freedom from ventricular arrhythmias (VAs) after endocardial ablation is limited. We compared the long-term freedom from recurrent VAs by using endocardial-alone ablation versus endo-epicardial substrate-based ablation. Forty-nine patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergoing ablation of ventricular tachycardia (VT) were divided into 2 groups: endocardial-alone ablation (group 1, n = 23) and endo-epicardial ablation (group 2, n = 26). All patients had an implantable cardioverter-defibrillator (ICD). Conventional and 3D mappings were used to determine the mechanism of induced VTs and to identify area of "scar" or "abnormal" myocardium. All critical sites responsible for VTs and points with "abnormal" potential were targeted for ablation from endocardium (group 1) or from both endocardium and epicardium (group 2). The procedural end point was noninducibility of sustained, monomorphic VT with isoproterenol. The presence of frequent premature ventricular contractions at the end of ablation was recorded. Patients were followed up by ECG, Holter, and ICD interrogation. After a follow-up of at least 3 years, freedom from VAs or ICD therapy was 52.2% (12/23) in group 1 and 84.6% (22/26) in group 2 (P = 0.029), with 21.7% (5/23) and 69.2% (18/26) patients off antiarrhythmic drugs (P < 0.001), respectively. Compared with patients with no premature ventricular contractions after ablation, patients with frequent premature ventricular contractions after ablation were more likely to have VA recurrence/ICD therapy [3/33 (9%) versus 12/16 (75%); log-rank P<0.001]. An endo-epicardial-based ablation strategy achieves higher long-term freedom from recurrent VAs off antiarrhythmic therapy in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy when compared with endocardial-alone ablation. The presence of ≥ 10 premature ventricular contractions per minute after ablation is associated with more VA recurrence.
          Article 0 comments Cited 46 times – based on 0 reviews     Review now
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            Long-term efficacy of catheter ablation of ventricular tachycardia in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy.

            Darshan Dalal, Rahul Jain, Harikrishna Tandri … (2007)
            This study sought to evaluate the outcomes of radiofrequency catheter ablation (RFA) of ventricular tachycardia (VT) in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) patients. Particular focus was placed on defining the single-procedure efficacy over long-term follow-up. ARVD/C is an inherited cardiomyopathy characterized by VT and right ventricular dysfunction. Prior single-center studies have reported conflicting results concerning the efficacy of RFA of VT in ARVD/C patients. The study population comprised 24 patients (age 36 +/- 9 years, 11 male), enrolled in the Johns Hopkins ARVD registry, who underwent 1 or more RFA procedures for treatment of VT. Patients were followed up for 32 +/- 36 months (range 1 day to 12 years). Recurrence was defined as the documentation of VT subsequent to the procedure. A total of 48 RFA procedures were performed using 3-dimensional electroanatomical (n = 10) or conventional (n = 38) mapping. Of these procedures, 22 (46%), 15 (31%), and 11 (23%) resulted in elimination of all inducible VTs, clinical VT but not all, and none of the inducible VTs, respectively. Forty (85%) procedures were followed by recurrence. The cumulative VT recurrence-free survival was 75%, 50%, and 25% after 1.5, 5, and 14 months, respectively. The cumulative VT recurrence-free survival did not differ by procedural success, mapping technique, or repetition of procedures. There was 1 procedure-related death. Our study shows a high rate of recurrence in ARVD/C patients undergoing RFA of VT. This likely reflects the fact that ARVD/C is a diffuse cardiomyopathy with progressively evolving electrical substrate. Further studies are needed to define the precise role of RFA of VT in ARVD/C.
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              Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in setting of right ventricular cardiomyopathy.

              David J Callans, Edward Gerstenfeld, Gauri H Nayak … (2004)
              To gain insight into the pathogenesis of right ventricular (RV) cardiomyopathy and ventricular tachycardia (VT), we determined the clinical and electroanatomic characteristics and outcome of ablative therapy in consecutive patients with (1) RV dilatation, (2) multiple left bundle-branch block (LBBB)-type VTs, and (3) an abnormal endocardial substrate defined by contiguous electrogram abnormalities. All 21 patients had detailed RV bipolar electrogram voltage mapping. Eighteen patients had simultaneous left ventricular (LV) mapping, including all 4 patients with right bundle-branch block (RBBB) VT. VT was ablated in 19 patients by use of focal and/or linear lesions with irrigated-tip catheters in 10 of 19 patients. Eighteen patients were men, age 47+/-18 years, and none had a family history of RV dysplasia. RV volume was 223+/-89 cm3. Electrogram abnormalities extended from perivalvular tricuspid valves (5 patients), pulmonic valves (6 patients), or both valves (10 patients). Electrogram abnormalities always involved free wall, spared the apex, and included the septum in 15 patients (71%). The area of abnormality was 55+/-37 cm2 (range, 12 to 130 cm2) and represented 34+/-19% of the RV. In 52 of 66 LBBB VTs, the origin was from the RV perivalvular region. LV perivalvular low-voltage areas noted in 5 patients were associated with a RBBB VT origin. No VT recurred after ablation in 17 patients (89%) during 27+/-22 months. In patients with RV cardiomyopathy and VT, (1) perivalvular electrogram abnormalities represent the commonly identified substrate and source of most VT, (2) LV perivalvular endocardial electrogram abnormalities and VT can occasionally be identified, and (3) aggressive ablative therapy provides long-term VT control.
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                Author and article information

                Contributors
                Vincenzo Lionetti: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 25 January 2017
                Publication date Collection: 2017
                Volume: 12
                Issue: 1
                Electronic Location Identifier: e0169863
                Affiliations
                [1 ]Guangdong Cardiovascular Institute, Guangzhou, P.R. China
                [2 ]Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, P.R. China
                [3 ]Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China
                Scuola Superiore Sant'Anna, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: XZ SW.

                • Data curation: WW HL JH.

                • Formal analysis: WW FL.

                • Funding acquisition: SW.

                • Investigation: WW HL.

                • Methodology: HL YX XF.

                • Project administration: SW.

                • Resources: WW YX XF FL HD Y. Liang.

                • Software: WW WL.

                • Supervision: SW XZ.

                • Validation: JH Y. Liu ZL.

                • Visualization: WW FL.

                • Writing – original draft: WW.

                • Writing – review & editing: WW XZ SW.

                Article
                Publisher ID: PONE-D-15-54809
                DOI: 10.1371/journal.pone.0169863
                PMC ID: 5266247
                PubMed ID: 28122031
                SO-VID: ad26c12b-da49-4617-9ebd-0ea080d21575
                Copyright © © 2017 Wei et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 21 December 2015
                Date accepted : 23 December 2016
                Page count
                Figures: 5, Tables: 3, Pages: 14
                Funding
                Funded by: National Five-year Science and Technology Supportive Program of China
                Award ID: No. 2011BAI11B13
                Award Recipient :
                Funded by: Science and technology Planning of Guangdong Province, China
                Award ID: No. 2014B070705005
                Award Recipient :
                This study was supported by the National Five-year Science and Technology Supportive Program of China “A study of idiopathic outflow-tract originated ventricular arrhythmias” (No. 2011BAI11B13) and the Science and Technology Planning of Guangdong Province, China “A study of early warning and intervention of malignant and potentially malignant ventricular arrhythmias” (No. 2014B070705005).
                Categories
                Subject: Research Article
                Subject: Biology and Life Sciences
                Subject: Biotechnology
                Subject: Medical Devices and Equipment
                Subject: Catheters
                Subject: Medicine and Health Sciences
                Subject: Medical Devices and Equipment
                Subject: Catheters
                Subject: Research and Analysis Methods
                Subject: Mathematical and Statistical Techniques
                Subject: Statistical Methods
                Subject: Multivariate Analysis
                Subject: Physical Sciences
                Subject: Mathematics
                Subject: Statistics (Mathematics)
                Subject: Statistical Methods
                Subject: Multivariate Analysis
                Subject: Research and Analysis Methods
                Subject: Bioassays and Physiological Analysis
                Subject: Electrophysiological Techniques
                Subject: Cardiac Electrophysiology
                Subject: Electrocardiography
                Subject: Research and Analysis Methods
                Subject: Mathematical and Statistical Techniques
                Subject: Statistical Methods
                Subject: Regression Analysis
                Subject: Physical Sciences
                Subject: Mathematics
                Subject: Statistics (Mathematics)
                Subject: Statistical Methods
                Subject: Regression Analysis
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Heart
                Subject: Epicardium
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Heart
                Subject: Epicardium
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Heart
                Subject: Myocardium
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Heart
                Subject: Myocardium
                Subject: Medicine and Health Sciences
                Subject: Cardiology
                Subject: Heart Failure
                Subject: Medicine and Health Sciences
                Subject: Cardiology
                Subject: Arrhythmia
                Custom metadata
                Data Availability All relevant data are within the paper and its Supporting Information files.

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