Non-ischaemic cardiomyopathy (NICM) encompasses a heterogeneous group of disorders
that includes genetic, idiopathic, post viral and inflammatory cardiomyopathies. NICM
is associated with an increased risk of ventricular arrhythmias (VAs), namely in the
form of ventricular tachycardia (VT). Although implanted cardiac defibrillators (ICD)
may prevent sudden death from VA, NICM patients may suffer from recurrent symptoms
and ICD therapies, and anti-arrhythmic drug side effects. Catheter ablation is highly
efficacious in NICM, however poses unique challenges when compared to post myocardial
infarction substrates. NICM substrates are fundamentally different in scar location,
extent, and transmurality which results in variable electrophysiologic properties
and less apparent ablation targets during sinus rhythm, compared to ischaemic cardiomyopathy.
NICM substrates can be intramural and/or epicardial, posing challenges to accessibility,
which likely accounts for the observed higher rates of arrhythmia recurrence following
ablation. Substrate location is influenced by the underlying aetiology (inflammatory,
genetic), and can be gleaned from a combination of unique 12-lead electrocardiogram
VT patterns, distribution of late gadolinium enhancement on cardiac magnetic resonance
imaging, and electroanatomic voltage mapping. With the high proportion of intramural
substrate in NICM, novel techniques have become increasingly common in recent years,
including sequential, simultaneous or bipolar ablation on opposite myocardial surfaces
to achieve greater lesion depth; use of half normal saline for irrigation; use of
a novel retractable needle within an endocardial catheter; and transcoronary/venous
ethanol ablation to target more inaccessible regions. Epicardial approaches have also
been improved in recent years, with advents such as the needle-in-needle technique
to reduce the risk of pericardial bleeding and phrenic nerve displacement, and hybrid
surgical approaches to facilitate epicardial access in the presence of adhesions.
Non-invasive cardiac radiation holds promise for the future. This state-of-the-art
review will summarise the incidence, mechanism, multimodal assessment and catheter
ablation-based management of VA in NICM.
Abbreviations:
cMRI (cardiac magnetic resonance imaging), DCM (dilated cardiomyopathy), EGM (electrogram), ICD (implanted cardiac defibrillator), ICM (ischaemic cardiomyopathy), LMNA (lamin A/C mutation), LV (left ventricle), LVEF (left ventricular ejection fraction), MRI (magnetic resonance imaging), NICM (non ischaemic cardiomyopathy), PVC (premature ventricular contractions), RF (radiofrequency), VA (ventricular arrhythmia), VF (ventricular fibrillation), VT (ventricular tachycardia)Keywords
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Article info
Publication history
Published online: October 17, 2018
Identification
Copyright
© 2018 Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
