Should all patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergo epicardial catheter ablation?

BACKGROUND: Epicardial radiofrequency catheter ablation is currently considered as the therapeutic option of choice in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) and recurrent ventricular tachycardia (VT). We hypothesised that inducibility of VT may guide the ablation strategy and thereby affect long-term results. Additional epicardial ablation was only performed if VT were still inducible after thorough endocardial ablation.
METHODS: The objective was to examine an inducibility-guided ablation approach by comparing the long-term results between endocardial and epi-endocardial radiofrequency catheter ablation of VT in a large cohort of patients with ARVD/C.
RESULTS: We studied from our ARVD/C registry (70 patients in total, 48 males, age 53.2 ± 14.0) 45 patients (64.3% of all patients) who underwent catheter ablation of VT. All patients received endocardial VT ablation. After endocardial ablation, 24 patients (53.3%) remained inducible. Additional epicardial ablation was performed in 22 patients (48.9%). After ablation, non-inducibility was achieved in overall 38 patients (84.4%). During a mean follow-up of 31.1 ± 27.4 months, 13 patients in each group (59.1% after endo- and epicardial ablation, 56.5% after endocardial ablation) remained free from VT recurrence (P = 0.862).
CONCLUSIONS: An inducibility-guided catheter ablation strategy of VT in patients with ARVD/C prevents unnecessary epicardial ablation and may therefore be considered as an alternative to primary combined endo- and epicardial ablation.