title: Necessity of epicardial ablation for ventricular tachycardia after sequential endocardial approach.
abstract: BACKGROUND
  Catheter ablation (CA) of ventricular tachycardia (VT) is an important treatment option in patients with structural heart disease (SHD) and implantable cardioverter defibrillator (ICD). A subset of patients requires epicardial CA for VT.
  
  
  OBJECTIVE
  The purpose of the study was to assess the significance of epicardial CA in these patients after a systematic sequential endocardial approach.
  
  
  METHODS
  Between January 2009 and October 2012 CA for VT was analyzed. A sequential CA approach guided by earliest ventricular activation, pacemap, entrainment and stimulus to QRS-interval analysis was used. Acute CA success was assessed by programmed ventricular stimulation. ICD interrogation and 24h-Holter ECG were used to evaluate long-term success.
  
  
  RESULTS
  One hundred sixty VT ablation procedures in 126 consecutive patients (114 men; age 65±12years) were performed. Endocardial CA succeeded in 250 (94%) out of 265 treated VT. For 15 (6%) VT an additional epicardial CA was performed and succeeded in 9 of these 15 VT. Long-term FU (25±18.2month) showed freedom of VT in 104 pts (82%) after 1.2±0.5 procedures, 11 (9%) suffered from repeated ICD shocks and 11 (9%) died due to worsening of heart failure.
  
  
  CONCLUSIONS
  Despite a heterogenic substrate for VT in SHD, endocardial CA alone results in high acute success rates. In this study additional epicardial CA following a sequential endocardial mapping and CA approach was performed in 6% of VT. Thus, due to possible complications epicardial CA should only be considered if endocardial CA fails.
authors.affiliation: University of Cologne, Heart Center, Department of Electrophysiology, Germany. Electronic address: arian.sultan@uk-koeln.de.
authors.forename: Arian
authors.initials: A
authors.lastname: Sultan
authors.affiliation: University of Cologne, Heart Center, Department of Electrophysiology, Germany.
authors.forename: Jakob
authors.initials: J
authors.lastname: Lüker
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Boris
authors.initials: B
authors.lastname: Hoffmann
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Helge
authors.initials: H
authors.lastname: Servatius
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Ali
authors.initials: A
authors.lastname: Aydin
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Jana
authors.initials: J
authors.lastname: Nührich
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Özge
authors.initials: Ö
authors.lastname: Akbulak
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Doreen
authors.initials: D
authors.lastname: Schreiber
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Schäffer
authors.affiliation: University Hospital Mainz, Department of Cardiology/Electrophysiology, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Rostock
authors.affiliation: University Heart Center Hamburg, Department of Cardiac Electrophysiology, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Willems
authors.affiliation: University of Cologne, Heart Center, Department of Electrophysiology, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Steven
mesh_terms: D000368:Aged; D017115:Catheter Ablation / Q000379:methods*; D004699:Endocardium / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D010496:Pericardium / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D017180:Tachycardia, Ventricular / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Epicardial ablation in structural heart disease