Apical ventricular tachycardia morphology in left ventricular nonischemic cardiomyopathy predicts poor transplant-free survival
Introduction
The area of low-voltage, abnormal bipolar electrograms consistent with “scar” in patients with left ventricular nonischemic cardiomyopathy (NICM) and ventricular tachycardia (VT) typically originates at or near the mitral annular region and extends a variable distance toward the apex.1 While patients with VT and NICM as a whole have better survival than those with VT and ischemic cardiomyopathy,2 there remains substantial variability in survival among those with NICM. We hypothesized that patients with NICM and VT morphologies suggesting an apical left ventricular exit site would have larger scars extending a greater distance from the base toward the apex and, consequently, worse transplant- and left ventricular assist device (LVAD)-free survival following ablation.
Section snippets
Study population
We studied consecutive patients with left ventricular NICM and sustained VT, who were referred to the Hospital of the University of Pennsylvania for ablation between May 2008 and April 2011. Patients with idiopathic VT, right ventricular cardiomyopathy, or ischemic cardiomyopathy, as defined by history of myocardial infarction or obstructive coronary artery disease on angiography, were excluded. Patients undergoing multiple ablation procedures during this time period were included once, with
Baseline, VT, and voltage map characteristics
Of 76 patients with NICM undergoing VT ablation, 16 had apical VT documented on spontaneous 12-lead ECG and an additional 16 had apical VT induced during electrophysiology study for a total of 32 patients (42%; Table 1). A mean of 371 points were recorded per endocardial voltage map and 554 points per epicardial map. Epicardial mapping was performed in 51% of patients. Compared to those without apical VTs, those with apical VTs had lower LVEF (23.1% vs 35.7%; P = .001), wider native QRS
Discussion
In a consecutive series of 76 patients with nonischemic left ventricular cardiomyopathy undergoing VT ablation, we found that patients with apical VT morphologies had larger areas of scar extending further from the base toward the apex, as defined by endocardial and epicardial voltage mapping. Patients with apical VTs were also more likely to die or require heart transplant or LVAD for end-stage heart failure. Despite a mean follow-up of less than 1 year, more than one-quarter of the patients
Conclusions
Patients with NICM and apical VTs have larger areas of scar extending further from the base toward the apex and worse transplant/LVAD-free survival, despite similar LVEF. Particular attention should be paid to optimal heart failure management in these patients, with a more guarded prognosis.
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Cited by (26)
Ablation of Ventricular Arrhythmias From the Left Ventricular Apex in Patients Without Ischemic Heart Disease
2020, JACC: Clinical ElectrophysiologyCitation Excerpt :Regarding NICM, it has previously been reported that the substrate for VA is most commonly located at the basal periannular regions of the LV (14). Larger scars that extend from the periannular LV toward the apex have been associated with apical morphology VTs and worse transplant/LV assist device–free survival (15). Septal substrate, which may be intramural, is also well described in NICM and can be associated with multiple VA morphologies (16).
Catheter Ablation of VT in Non-Ischaemic Cardiomyopathies: Endocardial, Epicardial and Intramural Approaches
2019, Heart Lung and CirculationThe Surface Electrocardiograph in Ventricular Arrhythmias: Lessons in Localisation
2019, Heart Lung and CirculationVentricular Tachycardia Ablation in Nonischemic Cardiomyopathy
2018, JACC: Clinical Electrophysiology
This study was supported in part by the F. Harlan Batrus Research Fund and the Susan and Murray Bloom Fund.