Endo-epicardial ablation vs endocardial ablation for the management of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy: A systematic review and meta-analysis

J Cardiovasc Electrophysiol. 2020 Aug;31(8):2022-2031. doi: 10.1111/jce.14593. Epub 2020 Jun 18.


Background: The pathologic process of ARVC (arrhythmogenic right ventricular cardiomyopathy) typically originates in the epicardium or subepicardial layers with progression toward endocardium. However, in the most recent ARVC international task force consensus statement, epicardial ventricular tachycardia (VT) ablation is recommended as a Class I indication only in patients with at least one failed endocardial VT ablation attempt.

Objective: The aim of this meta-analysis is to assess the outcomes of ARVC patients undergoing combined endo-epicardial VT ablation, as compared to endocardial ablation alone.

Methods: A systematic review of PubMed, Embase, and Cochrane was performed for studies reporting clinical outcomes of endo-epicardial VT ablation vs endocardial-only VT ablation in patients with ARVC. Fixed-Effect model was used if I2 < 25 and the Random-Effects Model was used if I2 ≥ 25%.

Results: Nine studies consisting of 452 patients were included (mean age 42.3 ± 5.7 years; 70% male). After a mean follow-up of 48.1 ± 21.5 months, endo-epicardial ablation was associated with 42% relative risk reduction in VA recurrence as opposed to endocardial ablation alone (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.45-0.75; P < .0001). No significant differences were noted between endo-epicardial and endocardial VT ablation groups in terms of all-cause mortality (RR, 1.19; 95% CI, 0.03-47.08; P = .93) and acute procedural complications (RR, 5.39; 95% CI, 0.60-48.74; P = .13).

Conclusions: Our findings suggest that in patients with ARVC, endo-epicardial VT ablation is associated with a significant reduction in VA recurrence as opposed to endocardial ablation alone, without a significant difference in all-cause mortality or acute procedural complications.

Keywords: arrhythmogenic right ventricular cardiomyopathy; endocardial ablation; endocardial-epicardial ablation; mortality; ventricular arrhythmia recurrence; ventricular tachycardia.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adult
  • Arrhythmogenic Right Ventricular Dysplasia* / complications
  • Arrhythmogenic Right Ventricular Dysplasia* / diagnosis
  • Arrhythmogenic Right Ventricular Dysplasia* / surgery
  • Catheter Ablation* / adverse effects
  • Endocardium / surgery
  • Female
  • Humans
  • Male
  • Pericardium / surgery
  • Recurrence
  • Tachycardia, Ventricular* / diagnosis
  • Tachycardia, Ventricular* / surgery
  • Treatment Outcome