Comparison of the arrhythmogenic substrate for ventricular tachycardia in patients with ischemic vs non-ischemic cardiomyopathy: insights from high-density, multi-electrode catheter mapping

Purpose: The purpose of this study was to compare the differences of arrhythmogenic substrate using high-density mapping in ventricular tachycardia (VT) patients with ischemic (ICM) vs non-ischemic cardiomyopathy (NICM). Methods: Data from patients presenting for VT ablation from December 2016 to December 2020 at Westmead Hospital were reviewed. Results: Sixty consecutive patients with structural heart disease (ICM 57%, NICM 43%, mean age 66 years) having catheter ablation of scar-related VT with pre-dominant left ventricular involvement were included. ICM was associated with larger proportion of dense scar area (bipolar; 19 [12–29]% vs 6 [3–10]%, P < 0.001, unipolar; 20 [12–32]% vs 11 [7–19]%, P = 0.01) compared with NICM. However, the scar ratio (unipolar dense scar [%]/bipolar dense scar [%]) was significantly higher in NICM patients (1.2 [0.8–1.7] vs 1.7 [1.3–2.3], P = 0.003). Larger scar area in ICM was paralleled by higher proportion of complex electrograms (6 [2–13] % vs 3 [1–5] %, P = 0.01), longer and wider voltage based conducting channels, higher incidence of late potential-based conducting channels, longer VT cycle-length (399 ± 80 ms vs 359 ± 68 ms, P = 0.04) and greater maximal stimulation-QRS interval among sites with good pace-map correlation (75 [51–99]ms vs 48 [31–73]ms, P = 0.02). Ventricular arrhythmia (VA) storm was more highly prevalent in ICM than NICM (50% vs 23%, P = 0.03). During the follow-up period, NICM had a significantly higher cumulative incidence for the VA recurrence than ICM (P = 0.03). Conclusions: High-density multi-electrode catheter mapping of left ventricular arrhythmogenic substrate of NICM tends to show smaller dense scar area and higher scar ratio, compared with ICM, suggestive the extent of epicardial/intramural substrate, with paucity of substrate targets for ablation, which results in the worse outcomes with ablation.