Endo-Epicardial vs. Endocardial-Only Catheter Ablation of Ventricular Tachycardia in Patients With Ischemic Cardiomyopathy: The EPIC-VT Trial Design.

Abstract

Introduction: Radiofrequency ablation is a cornerstone therapy for patients with ischemic cardiomyopathy (ICM) presenting with ventricular tachycardia (VT). In this context, ablation is typically performed endocardially as a first-line approach. However, despite acute procedural success, the risk of recurrence remains high, potentially due to the presence of epicardial substrate. Several observational studies have suggested the potential benefits of a first-line endo-epicardial approach in decreasing recurrence. In this context, the EPIC-VT trial was designed to compare endocardial-only ablation versus combined endo-epicardial ablation as a first-line approach in ICM patients with VT.

Methods: The EPIC-VT trial is a prospective, multicenter, controlled, randomized, open-label superiority trial with two parallel groups (endocardial-only approach vs. combined endo-epicardial approach) in a 1:1 ratio. The primary objective of this study is to demonstrate that a combined endo-epicardial approach reduces the risk of VT recurrence compared to an endocardial approach alone in patients with ICM. Patients will be followed for 2 years after the procedure.

Results and conclusion: To date, only retrospective studies have compared VA recurrences in patients with ICM, depending on whether ablation was performed using an endocardial or an endo-epicardial approach, with conflicting results. A meta-analysis suggested an advantage of the endo-epicardial approach over the endocardial approach (odds ratio = 0.39 [95% CI: 0.18-0.83]). However, the level of evidence remains low, and no controlled randomized study has confirmed this hypothesis. If the EPIC-VT study confirms the superiority of a first-line endo-epicardial approach, such strategy could become the preferred option for VT ablation in ICM, thereby reducing the risk of VA recurrence.