Outcomes of endocardial versus endo-epicardial catheter ablation for ventricular arrhythmia in patients with arrhythmogenic right ventricular cardiomyopathy: a meta analysis

BACKGROUND: Ventricular tachycardia (VT) ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC) is typically performed using an endocardial first approach. However, epicardial involvement is common and recurrence remains frequent. We therefore compared the pooled efficacy and safety of endocardial-only versus combined endocardial and epicardial ablation strategies. METHODS: We performed a systematic review and Bayesian meta-analysis of studies comparing endocardial and endo-epicardial VT ablation in patients with ARVC, including single- and double-arm designs. Ventricular arrhythmia (VA) recurrence was the primary endpoint and major complications were secondary. Bayesian methods were used to estimate pooled odds ratios (ORs) with 95% credible intervals (CrIs), with posterior predictive checks assessing model fit. A frequentist random-effects meta-analysis of double-arm studies was also conducted. Individual patient data (IPD) reconstructed from Kaplan-Meier curves enabled pooled survival analyses and hazard ratio (HR) estimation for VA recurrence. RESULTS: Seventeen studies including 976 patients reporting primary or secondary outcomes were analyzed. Endo-epicardial ablation in ARVC was associated with a significantly lower risk of ventricular arrhythmia (VA) recurrence (Bayesian OR 0.47, 95% CrI 0.34-0.64), with similar frequentist analysis results (OR 0.48, 95% CI 0.30-0.75, p = 0.001). Reconstructed IPD from 460 patients showed reduced VA recurrence (HR 0.39, 95% CI 0.28-0.52; log-rank p < 0.001). Across 15 studies (866 patients), the combined approach increased complication risk (Bayesian OR 6.28, 95% CI 2-24). The frequentist model demonstrated a comparable increase (OR 3.19, 95% CI 1.02-10, p = 0.047). CONCLUSION: Endo-epicardial ablation reduced VA recurrence but increased major complication risk compared with endocardial ablation.