Ablation of ventricular tachycardia from right ventricular aneurysms in patients with arrhythmogenic cardiomyopathy guided by intracardiac echocardiography

Abstract Background The best approach for ablating ventricular tachycardia (VT) targeting right ventricular free wall (RVFW) aneurysms in arrhythmogenic right ventricular cardiomyopathy (ARVC) remains undefined. Purpose We aimed to describe the technical approach, safety and long-term efficacy of endocardial ablation of VT originating from RVFW aneurysms in ARVC patients. Methods We identified ARVC patients with VT mapped to Intracardiac Echocardiography (ICE)-defined RVFW aneurysms who underwent endocardial ablation targeting the aneurysmal area. RVFW aneurysm on ICE was defined as an akinetic/dyskinetic area with diastolic bulging. The primary ablation endpoint was VT control defined as freedom from any or multiple (>1) VT recurrences. Results From 2012 to 2023, 14 ARVC patients underwent endocardial VT ablation within ICE-defined RVFW aneurysms (Figure 1 and Figure 2). The median age at first arrhythmia event was 55.5years (IQR 32.3-59.8years). Pathogenic genetic variants were identified in 82% of the patients. Ablation inside the RV aneurysms during ICE monitoring used prolonged radiofrequency applications (median 111 seconds, IQR 81–180 seconds), with power titrated up to 29W (IQR 29–33W) to achieve 10-15% impedance drops. No steam pops occurred. VT non-inducibility was achieved in 86% with no complications. During median follow-up of 4.3years (IQR 3.1–6.0years), the primary endpoint was achieved in 13 patients (93%): 10 VT-free, and 3 with a single episode of VT. Conclusion Endocardial ablation targeting VT from ICE-defined RVFW aneurysms in ARVC patients using prolonged RF applications is safe and effective, precluding the need for adjunctive epicardial ablation. Patients with aneurysm-dependent VT were typically older and carried pathogenic genetic variants.Figure 1 Figure 2