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.