Author + information
- Received August 26, 2019
- Revision received November 27, 2019
- Accepted November 27, 2019
- Published online April 20, 2020.
- Michael Ghannam, MDa,
- Konstantinos C. Siontis, MDa,
- Hyungjin Myra Kim, ScDa,
- Hubert Cochet, MD, PhDb,c,
- Pierre Jais, MDb,c,
- Mehdi Juhoor, Engrb,c,
- Rakesh Latchamsetty, MDa,
- Krit Jongnarangsin, MDa,
- Anil Attili, MDa,
- Ghaith Sharaf Dabbagh, MDa,
- Miki Yokokawa, MDa,
- Fred Morady, MDa and
- Frank Bogun, MDa,∗ ()
- aUniversity of Michigan, Ann Arbor, Michigan
- bBordeaux University Hospital and University of Bordeaux, Bordeaux, France
- cINRIA, Sophia Antipolis, France
- ↵∗Address for correspondence:
Dr. Frank Bogun, University of Michigan, Cardiovascular Center, Internal Medicine, Division of Cardiology, SPC 5853, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-5853.
Objectives The goal of this study was to assess the value of a stepwise, image-guided ablation approach in patients with cardiomyopathy and predominantly intramural scar.
Background Few reports have focused on catheter-based ventricular tachycardia (VT) ablation strategies in patients with predominantly intramural scar.
Methods The study included patients with predominantly intramural scar undergoing VT ablation. A stepwise strategy was performed consisting of a localized ablation guided by conventional mapping criteria followed by a more extensive ablation if VT remained inducible. The extensive ablation was guided by the location and extent of intramural scarring on delayed enhanced–cardiac magnetic resonance imaging. A historical cohort who did not undergo additional extensive ablation was identified for comparison. A novel measurement, the scar depth index (SDI), indicating the percent area of the scar at a given depth, was correlated with outcomes.
Results Forty-two patients who underwent stepwise ablation (median age 61 years [interquartile range: 55 to 69 years], 35 male patients, median left ventricular ejection fraction 36.0% [25.0% to 55.0%], ischemic [n = 4] or nonischemic cardiomyopathy [n = 38]) were followed up for a median of 17 months (8 to 36 months). A stepwise approach resulted in a 1-year freedom from VT, death, or cardiac transplantation of 76% (32 of 42). Patients who underwent additional extensive ablation had a lower risk of events than a clinically similar historical cohort (N = 19) (hazard ratio: 0.30; 95% CI: 0.13 to 0.68; p < 0.004). SDI>5mm was associated with worse long-term outcomes (hazard ratio: 1.03; 95% CI: 1.01 to 1.06%; p = 0.03), SDI>5mm >16.5% was associated with failed ablation (area under the curve: 0.84; 95% CI: 0.71 to 0.97).
Conclusions Stepwise ablation using delayed enhanced–cardiac magnetic resonance guidance is a novel approach to VT ablation in patients with predominantly intramural scarring. The SDI correlates with immediate procedural and long-term outcomes.
- cardiac magnetic resonance
- catheter ablation
- delayed enhancement
- intramural scar
- radiofrequency ablation
- ventricular tachycardia
This research was supported by funding from the French National Research Agency (ANR) under Grant Agreements Equipex MUSIC ANR-11-EQPX-0030, IHU LIRYC ANR-10-IAHU-04, and from the European Research Council under Grant Agreement ERC no. 715093. Dr. Jais reports having shares in InHeart. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received August 26, 2019.
- Revision received November 27, 2019.
- Accepted November 27, 2019.
- 2020 American College of Cardiology Foundation
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