Scar Homogenization Versus Limited-Substrate Ablation in Patients With Nonischemic Cardiomyopathy and Ventricular
Yalçın Gökoğlan1, Sanghamitra Mohanty2, Carola Gianni3
1Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Cardiology, Gülhane Military Academy of Medicine, Ankara, Turkey.
Insights
Scar homogenization significantly improves long-term ventricular arrhythmia freedom in nonischemic cardiomyopathy patients. This approach offers better outcomes than standard ablation for scar-related ventricular tachycardia (VT).
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Ventricular tachycardia (VT) in nonischemic cardiomyopathy presents unique challenges.
- The efficacy of scar homogenization for VT in this population is not well-established.
- Previous studies suggest scar homogenization benefits patients with ischemic cardiomyopathy.
Purpose of the Study:
- To evaluate the long-term effectiveness of endoepicardial scar homogenization versus standard ablation for scar-related VT.
- To compare procedural success and arrhythmia recurrence rates between the two ablation techniques.
- To identify predictors of long-term success in patients with nonischemic cardiomyopathy and VT.
Main Methods:
- A prospective study included 93 patients with dilated nonischemic cardiomyopathy and scar-related VT.
- Patients underwent either standard VT ablation (n=57) or endoepicardial scar homogenization (n=36).
- Electroanatomic mapping identified low-voltage regions (<1.5 mV) as targets for ablation.
Main Results:
- Scar homogenization achieved higher acute procedural success (69.4% vs. 42.1%, p=0.01).
- Long-term success rates were significantly better with scar homogenization (63.9% vs. 38.6%, p=0.031) over 14 months.
- Scar homogenization and left ventricular ejection fraction predicted long-term success; rehospitalization rates were lower.
Conclusions:
- Endoepicardial scar homogenization significantly increases freedom from recurrent ventricular arrhythmia in nonischemic cardiomyopathy.
- The approach shows promise but may have lower success rates than in ischemic cardiomyopathy due to scar distribution.
- Further research is warranted to optimize scar homogenization techniques for diverse cardiomyopathies.
Background:
Scar homogenization improves long-term ventricular arrhythmia-free survival compared with standard limited-substrate ablation in patients with post-infarction ventricular tachycardia (VT). Whether such benefit extends to patients with nonischemic cardiomyopathy and scar-related VT is unclear.
Objectives:
The aim of this study was to assess the long-term efficacy of an endoepicardial scar homogenization approach compared with standard ablation in this population.
Methods:
Consecutive patients with dilated nonischemic cardiomyopathy (n = 93), scar-related VTs, and evidence of low-voltage regions on the basis of pre-defined criteria on electroanatomic mapping (i.e., bipolar voltage <1.5 mV) underwent either standard VT ablation (group 1 [n = 57]) or endoepicardial ablation of all abnormal potentials within the electroanatomic scar (group 2 [n = 36]). Acute procedural success was defined as noninducibility of any VT at the end of the procedure; long-term success was defined as freedom from any ventricular arrhythmia at follow-up.
Results:
Acute procedural success rates were 69.4% and 42.1% after scar homogenization and standard ablation, respectively (p = 0.01). During a mean follow-up period of 14 ± 2 months, single-procedure success rates were 63.9% after scar homogenization and 38.6% after standard ablation (p = 0.031). After multivariate analysis, scar homogenization and left ventricular ejection fraction were predictors of long-term success. During follow-up, the rehospitalization rate was significantly lower in the scar homogenization group (p = 0.035).
Conclusions:
In patients with dilated nonischemic cardiomyopathy, scar-related VT, and evidence of low-voltage regions on electroanatomic mapping, endoepicardial homogenization of the scar significantly increased freedom from any recurrent ventricular arrhythmia compared with a standard limited-substrate ablation. However, the success rate with this approach appeared to be lower than previously reported with ischemic cardiomyopathy, presumably because of the septal and midmyocardial distribution of the scar in some patients.
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