Epicardial only mapping and ablation of ventricular tachycardia: a case series

Ventricular tachycardia (VT) ablation for ventricular arrhythmias is a validated approach, typically performed endocardially, or combined with an epicardial approach if endocardial ablation failed or in case of non-ischaemic cardiomyopathy. We report our experience with epicardial only procedure in a subset of patients with incessant VT or VT storm.

This was a single centre retrospective study. Between 2011 and 2014, all patients referred for VT ablation were reviewed at CHU Bordeaux. All patients with an epicardial only (anterior percutaneous approach) mapping and ablation procedure were included. In total, 296 patients underwent a VT ablation and 4 (all male, 70 ± 7 years, 27 ± 11% left ventricular ejection fraction) of them underwent an epicardial only procedure: two ischaemic patients had an endocardial left ventricular thrombus and incessant VT. One patient post-myocarditis had a failed a previous endocardial procedure without local abnormal ventricular activity (LAVA). The fourth patient had a dilated cardiomyopathy and a complicated epicardial puncture followed by mild continuous bleeding (200 mL) precluding anticoagulation associated with left ventricular endocardial access. Local abnormal ventricular activity elimination was verified only epicardially in all and obtained in two patients and non-inducibility was tested and achieved in the two patients without thrombus. No further complications occurred. After a mean follow-up of 21 ± 12 months, one patient (25%) had recurrence of VT and no patient death was observed.

Epicardial only ablation seems feasible and effective and useful in a limited subset of patients with incessant VT. However, endpoints are more difficult to evaluate and long-term follow-up is needed.