title: Infarct transmurality as a criterion for first-line endo-epicardial substrate-guided ventricular tachycardia ablation in ischemic cardiomyopathy.
abstract: BACKGROUND
  There is no consensus on the appropriate indications for the epicardial approach in substrate ablation of post-myocardial infarction (MI) ventricular tachycardia (VT).
  
  
  OBJECTIVE
  The purpose of this study was to investigate whether infarct transmurality (IT) could identify patients who would benefit from a combined first-line endo-epicardial approach.
  
  
  METHODS
  Before ablation, IT was assessed by contrast-enhanced cardiac magnetic resonance imaging (hyperenhancement ≥75% of the wall thickness in ≥1 segment), echocardiography (dyskinesia/akinesia + hyperrefringency + wall thinning), computed tomography (wall thinning), or scintigraphy (transmural necrosis). Prospectively from January 2011, an endocardial approach was used in patients with subendocardial MI (group 1) and a combined endo-epicardial approach in patients with transmural MI (group 2). Outcomes in both groups were compared with those in patients with transmural MI and only endocardial approach due to previous cardiac surgery or procedure performed before January 2011 (group 3). The primary end point was VT/ventricular fibrillation recurrence-free survival.
  
  
  RESULTS
  Ninety patients (92.2% men; mean age 67.4 ± 9.8 years) undergoing VT substrate ablation were included: group 1, n = 34; group 2, n = 24; group 3, n = 32. During a mean follow-up duration of 22.5 ± 13.7 months, 5 patients in group 1 (14.7%), 3 patients in group 2 (12.5%), and 13 patients in group 3 (40.6%) had VT recurrences (P = .011). Time to recurrence was the shortest in group 3 (log-rank, P = .018). The endocardial approach in patients with transmural MI was associated with an increased risk of recurrence (hazard ratio 4.01; 95% confidence interval 1.41-11.3; P = .009).
  
  
  CONCLUSIONS
  The endocardial approach in patients with transmural MI undergoing VT substrate ablation is associated with an increased risk of recurrence. IT may be a useful criterion for the selection of a first-line combined endo-epicardial approach.
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Juan
authors.initials: J
authors.lastname: Acosta
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Juan
authors.initials: J
authors.lastname: Fernández-Armenta
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Diego
authors.initials: D
authors.lastname: Penela
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: David
authors.initials: D
authors.lastname: Andreu
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Roger
authors.initials: R
authors.lastname: Borras
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Francesca
authors.initials: F
authors.lastname: Vassanelli
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Viatcheslav
authors.initials: V
authors.lastname: Korshunov
authors.affiliation: Radiology Department, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain.
authors.forename: Rosario J
authors.initials: RJ
authors.lastname: Perea
authors.affiliation: Radiology Department, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain.
authors.forename: Teresa M
authors.initials: TM
authors.lastname: de Caralt
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Jose T
authors.initials: JT
authors.lastname: Ortiz
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Guillermina
authors.initials: G
authors.lastname: Fita
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Marta
authors.initials: M
authors.lastname: Sitges
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Josep
authors.initials: J
authors.lastname: Brugada
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain.
authors.forename: Lluis
authors.initials: L
authors.lastname: Mont
authors.affiliation: Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Catalonia, Spain,. Electronic address: berruezo@clinic.ub.es.
authors.forename: Antonio
authors.initials: A
authors.lastname: Berruezo
mesh_terms: D000368:Aged; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D004699:Endocardium / Q000503:physiopathology / Q000601:surgery; D056149:Epicardial Mapping / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications*; D016016:Proportional Hazards Models; D012008:Recurrence; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000209:etiology / Q000601:surgery; D016896:Treatment Outcome
keywords: Epicardial approach; Infarct transmurality; Ventricular tachycardia ablation