Christopher Reithmann1, Bernhard Herkommer2, Michael Fiek2. 1. Medizinische Klinik 1, Helios-Klinikum München West, Akademisches Lehrkrankenhaus der Ludwigs-Maximilians Universität München, Steinerweg 5, 81241, Munich, Germany. christopher.reithmann@helios-kliniken.de. 2. Medizinische Klinik 1, Helios-Klinikum München West, Akademisches Lehrkrankenhaus der Ludwigs-Maximilians Universität München, Steinerweg 5, 81241, Munich, Germany.
Abstract
BACKGROUND: Sustained ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) often involves midmyocardial and epicardial structures. Delayed-enhancement magnetic resonance imaging (DE-MRI) of scar and fibrosis is the method of choice to define the substrate of monomorphic VT. OBJECTIVE: The aim of the study was to compare the outcome of endocardial vs. epicardial VT ablation in patients with epicardial DE-MRI substrates in NICM. RESULTS: Among 44 patients with NICM referred for VT ablation who underwent DE-MRI, 12 patients had an epicardial-only (n = 4) or predominantly epicardial DE-MRI substrate (n = 8). 9 of the 12 patients had a prior myocarditis. Endocardial-only VT ablation was successful in two patients with epicardial DE-MRI substrate. A pericardial access for epicardial mapping and ablation was attempted in 8 patients and could be accomplished in seven. Epicardial low voltage (<1.5 mV) and very low voltage (<0.5 mV) areas were in good qualitative correlation to the epicardial DE-MRI substrates. Epicardial abnormal electrograms in combination with a good pace map QRS match were found in epicardial very low voltage areas in five patients and in low voltage areas in two patients. 2 patients with endocardial-only ablation, five patients with endo-epicardial ablation and two patients with primary epicardial ablation had a favorable post-ablation outcome (follow-up 32 ± 26 months) but one patient had to undergo heart transplantation for heart failure deterioration. CONCLUSIONS: Endo-epicardial ablation or primary epicardial ablation should early be considered in patients after myocarditis or with other forms of nonischemic cardiomyopathy with epicardial DE-MRI substrates.
BACKGROUND: Sustained ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) often involves midmyocardial and epicardial structures. Delayed-enhancement magnetic resonance imaging (DE-MRI) of scar and fibrosis is the method of choice to define the substrate of monomorphic VT. OBJECTIVE: The aim of the study was to compare the outcome of endocardial vs. epicardial VT ablation in patients with epicardial DE-MRI substrates in NICM. RESULTS: Among 44 patients with NICM referred for VT ablation who underwent DE-MRI, 12 patients had an epicardial-only (n = 4) or predominantly epicardial DE-MRI substrate (n = 8). 9 of the 12 patients had a prior myocarditis. Endocardial-only VT ablation was successful in two patients with epicardial DE-MRI substrate. A pericardial access for epicardial mapping and ablation was attempted in 8 patients and could be accomplished in seven. Epicardial low voltage (<1.5 mV) and very low voltage (<0.5 mV) areas were in good qualitative correlation to the epicardial DE-MRI substrates. Epicardial abnormal electrograms in combination with a good pace map QRS match were found in epicardial very low voltage areas in five patients and in low voltage areas in two patients. 2 patients with endocardial-only ablation, five patients with endo-epicardial ablation and two patients with primary epicardial ablation had a favorable post-ablation outcome (follow-up 32 ± 26 months) but one patient had to undergo heart transplantation for heart failure deterioration. CONCLUSIONS: Endo-epicardial ablation or primary epicardial ablation should early be considered in patients after myocarditis or with other forms of nonischemic cardiomyopathy with epicardial DE-MRI substrates.
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