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Outcomes After Ventricular Tachycardia Ablation without a back-up ICD in Arrhythmogenic Right Ventricular Cardiomyopathy: a Multicenter
International Study
Mikael Laredo, Estelle Gandjbakhch, Antonio Berruezo, Jean-Basptiste Gourraud, Raphael Martins, Tom Wong, Jean-Marc Sellal,
Frederic Sacher, Laurent Pison, Etienne Pruvot, Saurabh Kumar, Paolo Della Bella, Philippe Maury
Sorbonne Université University Hospital Pitié-Salpêtrière
Paris, France
Conflicts of interest
Company Disclosure
Biotronik Fellowship grant & travel grants
Boston Scientific Fellowship grant
Microport CRM Fellowship grant & travel grants
Medtronic Fellowship grant & travel grants
Biosense Webster Fellowship grant
Monomorphic VT: 3-5%/y
Sudden death (SD): 0.5-1%/yCalkins et al., Circulation, 2017
ARVC: A high-burden of ventricular arrhythmias
ICD-related complications: ≈20%Considerable morbidityYoung population
Implantable cardioverter-defibrillator Catheter ablation
Santangelli et al., Circ. EP, 2017
Long-term recurrences: 15-50%VT recurrence ≠ Sudden death
VT management in ARVC
Schinkel, Circ. EP, 2013
Current guidelines
International Task Force Consensus document, 2017
Catheter ablation may be indicated as
first choice therapy without a back-up
ICD for selected patients with drug-
refractory, haemodynamically stable,
single-morphology VT (class IIb)
67 Patients from 6 European centers:
• With a definite ARVC according to the 2010 Task Force revised criteria
• Who underwent RCA of well-tolerated monomorphic VT at 9 tertiary centers across
5 countries (2005-2016)
• Without an ICD prior to RCA and in the 3 following months
• Without:
• Syncope or electrical storm as initial presentation
• Left ventricular ejection fraction < 50%
Methods
Patient clinical characteristics (n=67 patients)
Demographical dataMean age, years 45±19Male sex, n (%) 50 (75)Pathogenic mutation, n (%) 18 (27)
ECG dataɛ-wave 12 (19)T-wave inversion beyond V2 30 (50)
Structural dataRVEF, % 47 (25-70)LVEF, % 61 (50-70)RVEF < 40% or RFAC < 33% 17 (56)
Mode of presentationPalpitations, n (%) 51 (81)Presyncope, n (%) 9 (14)Compensated heart failure, n (%) 1 (2)
Anti-arrhythmic medicationAmiodarone, n (%) 6 (9)Class I, n (%) 25 (37)Β-blockers alone, n (%) 12 (18)Sotalol, n (%) 6 (9)None 10 (15)
ArrhythmiaPrevious VT ablation, n (%) 10 (15%)VT rate, bpm 185±32> 1 clinical VT morphology, n (%) 1 (2%)
Electrophysiological study and radiofrequency catheter ablation
Approach
Endocardial only, n (%) 45 (69)
Endocardial + epicardial, n (%) 19 (29)
Epicardial only, n (%) 1 (2)
Electrophysiological study data
N. of induced VTs, n 1 (0-4)
≥ 2 induced VTs, n (%) 16 (23%)
Clinical VT inducible 52 (84)
Catheter ablation characteristics
N. of targeted RV sites, n 1 (1-3)
≥ 2 targeted RV sites, n (%) 11 (16)
RVOT, n (%) 21 (72)
Inferolateral RV, n (%) 23 (36%)
Procedural outcomes 6 (9)
Full success, n (%) 46 (72)
Partial success, n (%) 6 (9)
Failure, n (%) 3 (5)
Undertermined, n (%) 9 (14)
• 25-yo male• Professional cyclist• Uncle s/p SCD• Several episodes of palpitations during exercice• No syncope• Admitted to ICU for wide-QRS tachycardia• Lightheadedness but conserved hemodynamics
Clinical Case
• TTE/MRI: mildly dilated RV, free wall and subtricuspid bulging, LGE-
• Endo-epicardial RF VT ablation
• PKP2 mut
• 3.8 years uneventfull follow-up
Clinical Case
Bipolar ENDO 0.5-1.5 mV Bipolar EPI 0.5-1.5 mV
Results
0 12 24 36 48 60 72 840
10
20
30
40
50
60
70
80
90
100
Time after VT ablation (months)
Su
rviv
al w
ith
ou
t s
us
tain
ed
VT
re
cu
rre
nc
e (
%)
Number at risk:
65 50 42 33 26 17 13 9
0 12 24 36 48 60 72 840
10
20
30
40
50
60
70
80
90
100
Time after VT ablation (months)
Su
rviv
al w
ith
ou
t s
us
tain
ed
VT
re
cu
rre
nc
e (
%)
Epicardial ablation
Endocardial only ablation
P=0.005
Number at risk:
Epicardial: 19 18 16 13 9 4 12 1
Endocardial: 46 33 26 21 18 14 11 8
0 12 24 36 48 60 72 840
10
20
30
40
50
60
70
80
90
100
Time after VT ablation (months)
Su
rviv
al w
ith
ou
t s
us
tain
ed
VT
re
cu
rre
nc
e (
%)
Full success
No full success
P=0.004
Number at risk:
Full success: 46 38 32 26 19 11 9 6
No full success: 19 14 19 8 8 7 4 3
Long-term outcomes
• Selected patients (normal LV function, well-tolerated monomorphic VT) might be safely managed by VT ablation without a back-up ICD
– Those with a successful epicardial procedure are likely the best candidates
– No fatal event despite a significant rate of monomorphic VT recurrence
• ICD intervention for monomorphic VT does not equal SCD prevention
• Time for an evolution in guidelines of ARVC management ?
Conclusions
Thank you for your attention
, Mikael Laredo1*, Estelle Gandjbakhch1*, Antonio Berruezo2, Jean-Basptiste Gourraud3, Raphael Martins4, Tom Wong5, Jean-Marc Sellal6, Frederic Sacher7, Laurent Pison8, Etienne
Pruvot9, Saurabh Kumar10, Paolo DellaBella11, Philippe Maury12
1) Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Institut de Cardiologie, Paris, F-75013, France.2) Centro Médico Teknon, Barcelona, Spain
3) L'Institut du Thorax, Cardiologic Department and Reference Center for Hereditary Arrhythmic Diseases INSERM 1087, Boulevard Monod, Nantes, France
4) Service de Cardiologie et Maladies Vasculaires, CHU Rennes, Rennes, France; Université de Rennes 1, Rennes, France; U1099, INSERM, Rennes, France5) Cardiology Department, Royal Brompton and Harefield, London, United Kingdom
6) Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France; INSERM-IADI U1254, Vandœuvre lès-Nancy, France.
7) LIRYC Institute (L'Institut de RYthmologie et de modelisation Cardiaque)/Department of Cardiology, Bordeaux University Hospital, Bordeaux, France.8) Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
9) Cardiology Department, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland.10) Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW,
Australia11) Arrhythmia Department, San Raffaele Hospital, Milan, Italy.
12) Cardiology Division, Toulouse Rangueil University Hospital, Toulouse, France