Endo-epicardial vs endocardial-only catheter ablation of ventricular tachycardia: A meta-analysis

The efficacy of endocardial catheter ablation for ventricular tachycardia (VT) can be limited by intramural or epicardial substrates. Adding epicardial mapping and ablation may improve arrhythmia outcomes compared with an endocardial-only approach.

We performed a systematic review and meta-analysis of studies comparing a strategy of endo-epicardial catheter ablation to an endocardial-only approach for VT. Subanalyses were performed for ischemic and nonischemic cardiomyopathies.

A total of 22 studies including 1138 patients were included in the meta-analysis. Of those, 44% underwent an endo-epicardial approach. During intermediate to long-term follow-up (average 7 to 70 months), recurrent VT or appropriate implantable cardioverter defibrillator (ICD) therapies were significantly lower with the endo-epicardial strategy (OR, 0.52; P < .01). All-cause mortality was also lower in this group (OR, 0.50; P = .03). No difference between endo-epicardial and endocardial-only ablation was noted in nonischemic cardiomyopathies. Among 323 patients with ischemic cardiomyopathy, recurrent VT or appropriate ICD therapies was less frequent in the endo-epicardial group (OR, 0.39; P = .01), as was all-cause mortality (OR, 0.38; P = .05). In patients with arrhythmogenic right ventricular cardiomyopathy, recurrent VT or appropriate ICD therapy was also lower in the endo-epicardial group (OR, 0.42; P = .04).

These results suggest that a strategy of combined endo- and epicardial access for mapping and ablation of VT may provide superior efficacy to an endocardial-only approach in selected patients. Randomized trials are warranted to further investigate this question.