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