Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease: A Systematic Review and Meta-Analysis

Jorge Romero, Roberto C. Cerrud-Rodriguez, Luigi Di Biase, Juan Carlos Diaz, Isabella Alviz, Vito Grupposo, Luis Cerna, Ricardo Avendano, Usha Tedrow, Andrea Natale, Roderick Tung, Saurabh Kumar

Research output: Contribution to journalArticlepeer-review

65 Scopus citations


Objectives: This study sought to determine whether combined endocardial-epicardial (endo-epi) ablation was superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT). Background: Limited single-center studies suggest that combined endo-epi ablation strategy may be superior to endocardial ablation (endo) alone in patients with nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), and ischemic cardiomyopathy (ICM). Methods: A systematic review of Medline, Cochrane, and Embase databases was performed for studies that reported outcomes comparing endo-epi with endo VT ablation alone. Results: Seventeen studies consisting of 975 patients were included (mean 56 ± 10 years of age; 79% male; NICM in 36.6%; ICM in 32.8%; and ARVC in 30.6%). After a mean follow-up of 27 ± 21 months, endo-epi ablation was associated with a 35% reduction in risk of VT recurrence compared with endocardial ablation alone (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.55 to 0.78; p < 0.001). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR: 0.43; 95% CI: 0.28 to 0.67; p = 0.0002) and ARVC (RR: 0.59; 95% CI: 0.43 to 0.82; p = 0.0002), with a nonsignificant trend in NICM (RR: 0.87; 95% CI: 0.70 to 1.08; p = 0.20). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR: 0.56; 95% CI: 0.32 to 0.97; p = 0.04). Acute procedural complications were higher with the endo-epi approach (RR: 2.62; 95% CI: 0.91 to 7.52; p = 0.07). Conclusions: This meta-analysis suggests that a combined endo-epi ablation is associated with a lower risk of VT recurrence and subsequent mortality than endo only VT ablation in patients with scar-related VT. Procedural complications, however, are higher with the endo-epi approach.

Original languageEnglish (US)
Pages (from-to)13-24
Number of pages12
JournalJACC: Clinical Electrophysiology
Issue number1
StatePublished - Jan 2019
Externally publishedYes


  • VT recurrence
  • arrhythmogenic right ventricular cardiomyopathy
  • catheter ablation
  • endocardial ablation
  • epicardial ablation
  • ischemic cardiomyopathy
  • nonischemic cardiomyopathy
  • structural heart disease
  • ventricular tachycardia

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this