Preprocedural imaging guiding ventricular tachycardia ablation in structural heart disease

Afonso Nunes-Ferreira; Joana Brito; Nuno Cortez-Dias; Gustavo da Lima da Silva; Fausto J Pinto; João de Sousa

doi:10.1002/joa3.13205

Preprocedural imaging guiding ventricular tachycardia ablation in structural heart disease

J Arrhythm. 2024 Dec 19;41(1):e13205. doi: 10.1002/joa3.13205. eCollection 2025 Feb.

Authors

Afonso Nunes-Ferreira^{1

2

3}, Joana Brito^{1

2}, Nuno Cortez-Dias^{1

2}, Gustavo da Lima da Silva^{1

2}, Fausto J Pinto^{1

2}, João de Sousa^{1

2}

Affiliations

¹ Department of Cardiology ULSSM Lisbon Portugal.
² Lisbon School of Medicine CAML, CCUL@RISE, Universidade de Lisboa Lisbon Portugal.
³ Cardiology Department Hospital Lusíadas Amadora Lisbon Portugal.

Abstract

Background: Integration of preprocedural imaging techniques in ventricular tachycardia (VT) ablation may improve the identification of arrhythmogenic substrates, particularly relevant for patients with nonischemic cardiomyopathy (NICM) with sub-optimal outcomes. We assessed the impact of advanced preprocedural imaging on the safety and long-term efficacy of radiofrequency catheter ablation (RCA) for VT, comparing patients with NICM and ischemic cardiomyopathy (ICM).

Methods: In this prospective, single-center study, consecutive patients referred for scar-related VT ablation underwent multidetector computed tomography (MDCT) and late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Images were segmented with ADAS 3D software and integrated into mapping systems. Substrate map collection targeted the imaging-predicted area of interest and the ablation aimed at eliminating all local abnormal ventricular activities. Procedural safety was evaluated with 30-day mortality. Long-term efficacy was assessed by survival free from appropriate ICD shocks at 36 months.

Results: 102 patients were included (67 ± 11 years, 94% male; 75 ICM, 27 NICM). All patients underwent MDCT and 35% also underwent LGE-CMR. Procedural safety (4% 30-day mortality, p = .95) and 36-month efficacy were similar in both groups (88.0% vs. 74.1%, HR 2.09; p = .13 in ICM and NICM). Efficacy was higher in patients when VT activation mapping with VT isthmus ablation complemented substrate ablation compared to substrate-based ablation alone (94.5% vs. 80.6%, HR 4.00; p < .05).

Conclusion: A preprocedural imaging protocol integrated into the invasive mapping system may improve safety and long-term efficacy, with NICM patients exhibiting outcomes comparable to those with ICM. Activation mapping of the VT on top of substrate ablation may improve prognosis.

Keywords: VT ablation; cardiac magnetic resonance; ischemic cardiomyopathy; multidetector computed tomography; nonischemic cardiomyopathy.