Catheter Ablation of Ventricular Tachycardia, Ischemic Cardiomyopathy
Conditions
Keywords
ischemic cardiomyopathy
Brief summary
Radiofrequency ablation of ventricular tachycardias (VTs) is the gold standard treatment of refractory VTs in patients with ischaemic heart disease. In this setting, ablation is usually performed endocardially. However, even after a procedural success there is a high risk of recurrence, particularly due to the inability to create transmural lesions. Indeed, only the endocardium of the LV has been ablated, while a significant part of the arrhythmia substrate may be located on the other side of the myocardial thickness, on the epicardial side of the LV. First described in 1996, epicardial ablation, performed via a percutaneous subxyphoid approach, has since undergone considerable development. Electrophysiologists often use a double endo- and epicardial approach as first line therapy for the ablation of VTs complicating myocarditis or arrhythmogenic dysplasia of the right ventricle, where the substrate is most often epicardial. For VT in ischaemic heart disease, electrophysiologists perform endocardial ablation, and often perform epicardial ablation only after several endocardial failures. Several observational studies suggest that a combined endo- and epicardial approach as first line therapy is associated with a reduced risk of VT recurrence. Since recurrent VT in patients with ischaemic heart disease as a prognostic impact in terms of morbidity and mortality, it appears essential to optimise rhythm management by ablation, by offering a combined approach from the as first approach to reduce the risk of recurrences. The aim of our prospective, multicentre, controlled, randomized study is therefore to compare the rate of VT recurrence after ablation performed as first line therapy either by endocardial approach alone or by combined endo-epicardial approach.
Interventions
PROCEDUREEndo-epicardial ablation
Endo-epicardial ablation of ventricular tachycardia
PROCEDUREendocardial ablation only
endocardial-only catheter ablation of ventricular tachycardia
Sponsors
Rennes University Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Patients over 18 years of age 2. 1st radiofrequency ablation of VT complicating ischaemic heart disease 3. Patients with an ICD and remote monitoring 4. Having, for women of childbearing age, effective contraception until discharge from hospital 5. Have given their free and informed consent in writing 6. are affiliated to or have health insurance
Exclusion criteria
1. History of cardiac surgery compromising the epicardial approach (coronary artery bypass grafting, valve replacements, or other surgeries that may have caused pericardial adhesions) 2. Presence of a left intraventricular thrombus found during pre-procedure imaging 3. Anticoagulant therapy that cannot be temporarily discontinued 4. Double antiplatelet therapy that cannot be temporarily replaced by single antiplatelet therapy 5. History of pericarditis 6. Previous thoracic radiotherapy 7. Contraindication to general anaesthesia 8. Pregnant or breastfeeding woman 9. History of heparin-induced thrombocytopenia type 2 (as injection is required during the procedure) 10. Person under legal protection (safeguard of justice, curatorship, guardianship), deprived of liberty, or unable to express consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Survival free from ventricular arrhythmia recurrence | up to 5 years | Survival free from ventricular arrhythmia recurrence, defined as the time interval between the date of ablation and the date of first ventricular arrhythmia recurrence. Recurrence of ventricular arrhythmia is defined as the occurrence of appropriate ICD therapy or the occurrence ventricular arrhythmia requiring hospitalisation. The occurrence of the event and the date of the event will be obtained from the ICD interrogation. Patients without recurrence will be censored at the date of last ICD interrogation |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Percentage of patients with recurrent ventricular arrhythmia | up to 5 years | Percentage of patients with recurrent ventricular arrhythmia |
| Percentage of patients with a electrical storm | up to 5 years | Electrical storm is defined as the occurrence of at least 3 appropriate therapies (antitachycardia pacing or shocks) delivered by the defibrillator within 24 hours. |
| Number of serious complications | up to 5 years | Number of serious complications related to the procedure |
| Number of patients hospitalized for cardiovascular reasons | up to 2 years | Number of patients hospitalized for cardiovascular reasons (i.e. heart failure, rhythm disorders) at 2 years |
| Number of patients requiring a redo ablation for ventricular arrhythmia | Up to 5 years | Number of patients requiring a redo ablation for ventricular arrhythmia |
| Number of ventricular arrhythmias treated | up to 5 years | Number of ventricular arrhythmias treated by the defibrillator with shocks or bursts of antitachycardia pacing during follow-up or the occurrence of sustained VT/VF \> 30 seconds. |
| Number of patients in each group who are non-inducible at the end of the procedure | 1 day | Number of patients in each group who are non-inducible at the end of the procedure (programmed ventricular stimulation negative) |
| Length of hospital stay (from surgery to return home) | Up to 2 years | Length of hospital stay (from surgery to return home) (Day) |
| mortality rate | Up to 2 years | 2-year mortality rate |
Other
| Measure | Time frame | Description |
|---|---|---|
| Percentage of patients with inappropriate therapies deliverd by the ICD | Up to 2 years | Percentage of patients with inappropriate therapies deliverd by the ICD at 2 years |
| Survival free from ventricular arrhythmia recurrence according to the treatment modality | Up to 5 years | Describe the risk of recurrence of ventricular arrhythmias according to the treatment modality (combined endoepicardial approach vs epicardial approach alone) and according to the location of the substrate (anterior vs non-anterior, septal vs non-septal, apical vs non-apical, lateral vs non-lateral, and inferior vs non-inferior). |
| Procedure duration | 1 day | Procedure time (from puncture to catheter removal, in minutes) and duration of radiofrequency delivery (in minutes) |
Countries
France
Contacts
Primary ContactRaphaël MARTINS, MD, PhD
Backup ContactKristell COAT
Outcome results
None listed