Imaging -aided VT ablation. Long term Results from a Pilot Study

Imaging -aided VT ablation. Long term Results from a Pilot Study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Journal of Cardiovascular Electrophysiology This is a preprint and has not been peer reviewed. Data may be preliminary. 18 February 2025 V1 Latest version Share on Imaging -aided VT ablation. Long term Results from a Pilot Study Authors : Benjamin Sacristan 0009-0002-6139-0340 [email protected] , Hubert Cochet , Benjamin Bouyer 0000-0002-7702-7610 , Romain Tixier , Josselin Duchateau , Nicolas Derval , Thomas Pambrun , … Show All … , Marine Arnaud , Jan Charton , Geoffroy Ditac , Allan Plant , John Fitzgerald , Soumaya Sdiri-Cheniti , Laurens Verhaege , Michel Montaudon , Mélèze Hocini , Michel Haissaguerre , Maxime Sermesant , pierre jais , and Frederic Sacher Show Fewer Authors Info & Affiliations https://doi.org/10.22541/au.173988567.71221756/v1 Published Journal of Cardiovascular Electrophysiology Version of record Peer review timeline 309 views 264 downloads Contents Abstract ABSTRACT Introduction Methods Results Discussion Conclusion Bibliographic references Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract ABSTRACT Background VT ablation has become a cornerstone of patients care, especially for post MI VT. Several strategies have proven effective for achieving rhythm control in this population, but the workflow is highly variable and depends on physician experience. Aim This study describes the initial systematic experience of ventricular tachycardia (VT) ablation targeting wall thickness heterogeneity on cardiac computed tomography (CT) scanner used as surrogate for mapped VT isthmii. Methods Consecutive patients with post MI VT, a CT scan and a first VT ablation were included from January 2017 to May 2022. Targets were identified based on wall thickness heterogeneity. After image integration, ablation with >10 grams, 40-50 W was performed with the aim of blocking the CT channels/ render them non capturable. Only then inducibility was tested. Inducible VT, if any, were conventionally mapped and ablated with the aim of reaching non-inducibility. Results Thirty-nine patients (97.4% male, age: mean LVEF 35 ± 10%) were included. The mean number of identified CT Channels was 3.6 ± 1.8 / patient. Non-inducibility was achieved in 19 (48.7%) of patients after initial imaging guided ablation while at least one VT could be induced in 19 (48.7 %). Among these patients, 4 had VT related to unblocked or reconnected CT – determined VT channels, and 15 from other areas (border zone), typically with faster cycle length . After further mapping and ablation, 3 (7.7 %) patients remained inducible. Mean radiofrequency time was 35 ± 19 min for CT Channels ablation, with an additional 11 ± 8 min for supplementary ablation (global mean RF time 35 ± 19 min). With a mean follow-up of 47.8 ± 24.3 months, 61,9% (95% CI 44.0-75.5%) remained VT free. Conclusion CT-guided ablation represents a feasible and safe strategy for VT ablation in patients with an ischemic cardiomyopathy. Keywords: Ventricular tachycardia, catheter ablation, CT-Scan, InHeart software, imaging Benjamin Sacristan 1,2 , Hubert Cochet 3,2 , Benjamin Bouyer 1,2 , Romain Tixier 1,2 , Josselin Duchateau 1,2 , Nicolas Derval 1,2 , Thomas Pambrun 1,2 , Marine Arnaud 1,2 , Jan Charton 1,2 , Geoffroy Ditac 1 , Allan Plant 1 , John Fitzgerald 1 , Soumaya Sdiri-Cheniti 3,2 , Laurens Verhaege 1 , Michel Montaudon 3,2 , Mélèze Hocini 1,2 , Michel Haissaguerre 1,2 , Maxime Sermesant 4 , Pierre Jais 1,2 , Frederic Sacher 1,2 1 Department of Cardiac Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France. 2 IHU LIRYC, Université de Bordeaux-Inserm U1045, Pessac, France. 3 Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France. 4 Inria, Asclepios team, Sophia Antipolis, France. ABSTRACT Background VT ablation has become a cornerstone of patients care, especially for post MI VT. Several strategies have proven effective for achieving rhythm control in this population, but the workflow is highly variable and depends on physician experience. Aim This study describes the initial systematic experience of ventricular tachycardia (VT) ablation targeting wall thickness heterogeneity on cardiac computed tomography (CT) scanner used as surrogate for mapped VT isthmii. Methods Consecutive patients with post MI VT, a CT scan and a first VT ablation were included from January 2017 to May 2022. Targets were identified based on wall thickness heterogeneity. After image integration, ablation with >10 grams, 40-50 W was performed with the aim of blocking the CT channels/ render them non capturable. Only then inducibility was tested. Inducible VT, if any, were conventionally mapped and ablated with the aim of reaching non-inducibility. Results Thirty-nine patients (97.4% male, age: mean LVEF 35 ± 10%) were included. The mean number of identified CT Channels was 3.6 ± 1.8 / patient. Non-inducibility was achieved in 19 (48.7%) of patients after initial imaging guided ablation while at least one VT could be induced in 19 (48.7 %). Among these patients, 4 had VT related to unblocked or reconnected CT – determined VT channels, and 15 from other areas (border zone), typically with faster cycle length . After further mapping and ablation, 3 (7.7 %) patients remained inducible. Mean radiofrequency time was 35 ± 19 min for CT Channels ablation, with an additional 11 ± 8 min for supplementary ablation (global mean RF time 35 ± 19 min). With a mean follow-up of 47.8 ± 24.3 months, 61,9% (95% CI 44.0-75.5%) remained VT free. Conclusion CT-guided ablation represents a feasible and safe strategy for VT ablation in patients with an ischemic cardiomyopathy. Keywords: Ventricular tachycardia, catheter ablation, CT-Scan, InHeart software, imaging Introduction The number of patients undergoing ventricular tachycardia (VT) ablation is growing, backed by randomized trials, leading to a class I recommendation in ischemic drug refractory VT (1). Substrate ablation has demonstrated its superiority to clinical VT ablation alone (2). However, there is no standardization of substrate ablation. It mainly relies on the electrophysiologist’s experience. Substrate ablation based on cardiac MRI or CT scan (3,4) have been described. It could be a more reproducible and exportable strategy. This study described our systematic initial experience using a workflow based on image guided VT ablation and its results. Once limited to activation mapping, pacing maneuvers and/or substrate analysis(5–7), imaging-guided ablation procedures are now appearing as an effective way to streamline the ablation strategy and procedure workflow in ischemic and non-ischemic cardiomyopathy. It allows to precisely identify anatomy, substrate, and collateral structures for more effective and safer procedures(8–11). Furthermore, software has been developed to produce advanced 3D modeling from CT scan or MRI to identify potential arrhythmia isthmuses. These data can be implemented in electroanatomic mapping (EAM) systems to guide ablation (12–14). Several studies indicate promising outcomes from using this type of tools as part of the ablation strategy in VT (3,4) . The objective of this study is to present the results of our cohort in the setting of ischemic cardiomyopathy, and explore the characteristics of residual VTs after an initial ablation strategy based on CT data. Methods Study design This study served as a pilot study to test the following image guided VT ablation strategy. We included all patients referred for de-novo VT ablation in the setting of ischemic cardiomyopathy who had a cardiac CT scan. Cardiac CT scan is systematically performed before scar related VT ablation in the absence of renal failure or true contrast agent allergy in our center, to rule out intra-cardiac thrombus (15). The CT scan was then processed as previously reported via a dedicated software (InHeart) (16). Briefly cardiac anatomy was segmented and ventricular myocardial thickness was mapped to define the MI scar area (<5mm). In this scar are from previous MI, areas of relatively preserved wall thickness are considered more likely to host surviving fibers (CT Channels, 2-5mm) while the most severe thinned areas (1-2mm) is more likely to act as a block/barrier during VT. The constructed 3D map was used to guide ablation to CT Channels (as a surrogate for VT isthmii). These CT channels were cross validated by 2 EPs (FS, PJ) and a radiologist (HC) (See Central Figure). Of note, targets were set at middle of the potential isthmii at the beginning of the study then switch to entrance and exit because of fast VT remaining inducible anchored on scar periphery and then to the thinnest part of the CT channels by the end of the study because of absence of block of the isthmus in some patients. After gaining venous and or arterial access, a quick map of pulmonary artery bifurcation as well as coronary sinus (for transeptal access) or aortic arch (for retroaortic approach) was performed to allow precise merging with CT images. After accessing LV, reliability of the merging was assessed with the ablation catheter (Termocool ST/SF, Biosense Webster) placed at the LV apex, inferior, anterior, septal and lateral wall. CT channels were targeted using at least 10 grams, with a power of 40 to 50 W with the aim of rendering the area non capturable. After ablation of all identified CT channels, inducibility using up to 3 extrastimuli going down to 200ms from RV and LV was performed. If absence of inducible VT, the procedure was interrupted. In case of inducibility, the VT was targeted by activation mapping/pace-mapping with further ablation. Inducibility was tested again up to non-inducibility in absence of significant concerns for continuing the procedure. Patients were then followed-up as outpatient and via remote monitoring. Data extraction Patients provided written informed consent for data collection in accordance with French national law (MR-004) and recommendations from the Commission Nationale de l’Informatique et des Libertés (CNIL). Cardiac CT scan : Image acquisition Optimal hydration was performed before contrast injection particularly in patients with GFR between 30 and 50 ml/min. Image acquisition The standard imaging protocol involved pre-procedure cardiac CT (cCT) within 7 days of VT ablation. A dual-source scanner was used for imaging (SIEMENS DEFINITION from January 2015 to March 2017; SIEMENS FORCE from March 2017 to December 2019). Contrast volume was adapted to patient weight (1 mL/kg) with a contrast media concentration of 400 mg/mL iodine for normal renal function and 350 mg/mL if impaired. A dual-phase bolus was used (70% administered pure at 5–6 mL/s, immediately followed by 30% diluted 50/50 with saline at 5–6 mL/s). Arterial acquisition was performed at peak enhancement in the ascending aorta, with a volume comprising the whole heart and aortic arch. Tube voltage was 80–100 kV, and images were reconstructed at 0.6 mm slice thickness. Venous enhancement CT was acquired 60–90 seconds after contrast media injection, with a volume comprising only the heart and tube voltage lowered to 70–90 kV. In case of intraventricular or intra-atrial thrombus, the ablation procedure was postponed. Procedure workflow (see Central Figure) Procedures were performed under conscious sedation. Vascular access was obtained via the femoral vein and/or femoral artery. The left ventricle (LV) was accessed via a transseptal (BRK Needle, Agilis sheath, St. Jude Medical) and/or retrograde aortic approach. Following LV access, a 50U/kg heparin bolus was administered intravenously, with an ACT target pulmonary artery/aortic arch and the coronary sinus fast mapping was performed prior to ablation. Initial induction was not mandatory but left to operator’s discretion. After proper merging, a substrate map of the LV was made, using a multipolar catheter (Biosense Pentaray/Decanav, Boston Scientific Orion or Abbott HD Grid). Next step consisted of ablation of the prespecified isthmuses. Then inducibility was tested. If no VT was inducible, the procedure was ended. If the patient was inducible, further mapping and ablation was performed if needed. Localization (isthmuses or border zone) and tachycardia cycle length (TCL) were noted. Inducibility was tested at the end of the procedure as well. Follow-up VT recurrence or death was assessed via telephonic interview and ICD remote monitoring reports. Data analysis The primary endpoint was recurrent ventricular arrhythmia treated by the ICD or death. Follow-up data were obtained at regular intervals until the date of the last follow-up or event occurrence, whichever occurred first. Statistical Analysis Survival analysis was performed using the Kaplan-Meier estimator to calculate the probability of event-free survival (i.e., freedom from arrhythmia recurrence or death). Survival probabilities were estimated for predefined time points (e.g., 1, 2, and 4 years) and reported with corresponding 95% confidence intervals. Missing data is reported for each variable if present. All statistical analyses were conducted using Python (version 3.10.12) and relevant libraries, including pandas (version 2.2.2) for data extraction and analysis, Lifelines (version 0.29.0) for survival analysis and Matplotlib (version 3.7.1) for graphical representation of the Kaplan-Meier survival curve. The survival function was plotted using standard graphical parameters. Censored patients were appropriately indicated in the Kaplan-Meier plots. Results Cohort characteristics Thirty-nine patients (1 female, 64.0 ± 10.8 years old, LVEF 35.1 ± 10.1%) with ischemic CMP and de novo VT ablation were included. Baseline characteristics are described in Table 1 . Ten patients (25.6%) presented with electrical storm at admission. Substrate characterization CT-scan was performed for every patient. Characteristics of substrate for each patient with available data are described in Table 1. The mean number of CT Channels identified was 3.6 ± 1.8. Procedural characteristics Procedural characteristics are described in Table 2. No epicardial access was performed in this study. Mean procedural time was 197 ± 60 min. Mean fluoroscopy duration was 20 ± 7 min, and RF mean times were 41 ± 21 min. Ten patients underwent PES before ablation, three of them being inducible. 13 patients had mechanical induction prior to ablation, and 17 underwent ablation without prior PES. Initial isthmii ablation Clinical VT cycle length (recorded in 30 patients) as identified by ECG / ICD recordings was 375.8 ± 65.8 ms. The mean RF time for isthmus ablation was 35 ± 19 min. Inducibility after isthmus ablation 19 (48.7 %) patients were still inducible after initial isthmus ablation. Among them, 5 patients had VT originating from prespecified isthmii that were either not blocked or reconnected during the procedure. VTCL in these patients was slower (354 ± 44.8 ms). For the other patients, VT originated outside of the prespecified isthmii, typically from the border zone of the scar, with faster TCL (285.7 ± 34.1 ms). 3 patients were still inducible at the end of the procedure (7.7%). Complications No major complication occurred; 1 groin hematoma and one pseudo-aneurysm associated with arteriovenous fistulae, both managed conservatively. Follow-up Figure 2 Kaplan Meier curve details VT-free survival for the study cohort. Mean follow-up time was 47.8 ± 24.3 months. Six patients died of non-arrhythmic cause, one with history of recurrent VT treated by ICD shock. 11 patients had recurrent VT. Survival probability free from arrhythmia was estimated at 82.0 % at one year (95% CI: 66.0-91.0%), and 61.9% (95% CI 44.1-75.6%) at 48 months. Discussion This study provides insights into the advantages and limitations of a CT-guided approach to VT ablation in patients with ischemic cardiomyopathy. We demonstrated that this approach is safe, achieves acute non-inducibility in about half of VT cases without further ablation and have an 82.0% absence of VT recurrence or death at 1 year and 61.9% with a mean follow-up of 48 months, which is concordant with other data regarding catheter ablation in this population(2,17). Isthmus definition Since the ablation target is determined prior to the procedure, it is obvious that the identification of the potential isthmii condition the outcome of the ablation strategy. In our cohort, all ablation targets were determined by an experienced physician. This might constitute a limitation to a broader adoption of this kind of strategy to less experienced centers. However, simulation-based models have recently shown good results in automatic identification of VT channels related to endocardial scar (18). CT scan was the imaging modality of choice in this study, due to its better spatial resolution compared to MRI. Photon count CT, with its increased spatial resolution, might constitute an even better imaging modality for this type of strategy, but evidence is lacking in this area. Procedure workflow The CT-guided procedure for VT ablation provides a standardized workflow to achieved successful ablation; merging with CT data, ablation of prespecified isthmuses, assessment of inducibility, with complementary ablation if needed. The merging step of this approach is of particular importance to assure satisfying outcome. Our experience shows that a merge based on coronary sinus / aortic root mesh as well as the LV apex is the most effective way of achieving a good merge. We found out that using atrium geometry is longer and provides more shifting of the CT model. Procedure durations align with other studies exploring this anatomical approach: Berte et al. reported a procedural time of 172 ± 48 minutes (4), while Englert et al. noted 158.4 ± 71.1 minutes in their CT-imaging subgroups (3). Merging within electroanatomic mapping (EAM) systems is an additional step but is typically fast, taking less than 10 minutes in most cases, at most 15 min. This approach is suitable for less experienced centers as it standardizes the workflow and limits procedure and RF duration. Post-isthmus ablation findings After first-pass ablation, we identified two types of VTs: those originating from the isthmuses and faster circuits arising from the border zone, typically unrelated to previously ablated isthmuses. These fast VTs often require additional ablation strategies. For isthmus-related tachycardia, our ablation strategy evolved over the course of the study. Initially, we targeted the central isthmus, but later shifted towards a more peripheral approach. However, this strategy proved less effective in achieving complete isthmus block, likely due to the thicker myocardial wall in the border zone compared to the central scar, which reduced the likelihood of transmural lesions. This observation led us to revert to a more central isthmus ablation strategy. Our findings underscore the importance of (1) better defining target isthmuses before ablation to facilitate first-pass block and increase the non-inducibility rate, and (2) complementing this approach with additional ablation if clinically relevant VTs persist. Our data suggest that a CT-guided approach enables rapid and effective substrate simplification by targeting potential circuits within the scar. However, it does not address VTs arising outside these isthmuses, for which an optimal strategy remains to be determined. The extent to which fast, potentially non-sustained, and polymorphic VTs originating from the border zone should be treated remains an open question. In our experience, these fast VT circuits are difficult to map due to their haemodynamic tolerance but are typically anchored at the scar border zone. Given their persistence despite initial isthmus ablation, we adopted a stepwise strategy: first targeting the central isthmus and, if inducibility remained, performing border zone ablation guided by LAVA elimination and pacemapping. While this approach appears to yield the best results, further evaluation is required. Study strengths and limitations Innovative and Simplified Workflow One of the key strengths of this study is the detailed description of a standardized and reproducible workflow for CT-guided VT ablation. This approach streamlines the procedure, reducing variability and making it accessible to centers with less experience in VT ablation. By incorporating advanced imaging tools such as the MUSIC software for pre-procedural substrate identification, the workflow enhances precision in targeting arrhythmogenic isthmuses while optimizing safety and procedural efficiency. Extended Follow-Up Duration With a mean follow-up duration of 47.8 ± 24.3 months, this study provides one of the most comprehensive long-term datasets in the field. Retrospective and Non-Comparative Design The retrospective nature of this study inherently introduces biases and limits the ability to draw causal inferences. Additionally, the absence of a control group precludes direct comparisons with alternative strategies, such as conventional electrophysiological approaches. Insight from the upcoming multicentric randomized inEurHeart will hopefully provide more evidence on this part. Monocentric Cohort Being a single-center study, the findings may lack generalizability, particularly to lower-volume centers or those with different patient populations. Although the standardized nature of the workflow helps mitigate this limitation, external validation in multicenter settings is essential to confirm its broader applicability. Missing Data The study was constrained by missing data, particularly in relation to clinical VT characterization and radioprotection data, which is an inherent limitation of retrospective analyses. Heterogeneity in Ablation Strategies The evolution of the ablation strategy during the study period, from mid-isthmus to entrance/exit targeting and back, introduces some variability in the approach. While this reflects an adaptive learning curve, it complicates the assessment of the true efficacy of a single standardized protocol. Lack of Advanced Imaging Integration and new ablation technologies While CT was chosen for its superior spatial resolution and its wide availability, the absence of comparative data with other imaging modalities, such as MRI or photon-counting CT, limits the ability to assess whether the observed outcomes represent the optimal imaging-guided strategy. Furthermore, we have seen in the past years an increasing interest for new technologies such as pulsed field ablation, which constitute a promising new tool to provide better outcome for VT ablation, and its integration in this workflow remains to be explored. Conclusion CT-guided VT ablation is a feasible, safe and effective method to treat patients with ischemic cardiomyopathy presenting for a first VT ablation. Bibliographic references 1. Zeppenfeld K, Tfelt-Hansen J, De Riva M, Winkel BG, Behr ER, Blom NA, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. European Heart Journal. 21 oct 2022;43(40):3997‑4126. 2. Di Biase L, Burkhardt JD, Lakkireddy D, Carbucicchio C, Mohanty S, Mohanty P, et al. Ablation of Stable VTs Versus Substrate Ablation in Ischemic Cardiomyopathy: The VISTA Randomized Multicenter Trial. J Am Coll Cardiol. 29 déc 2015;66(25):2872‑82. 3. 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Figures Age (mean ± SD) 64.0 ± 10.8 Male gender (n, %) 38 (97.4%) LVEF (%) (mean ± SD) 35.1 ± 10.1 eGFR (ml/min) (mean ± SD) 82.3 ± 28.6 Time to myocardial infarction (months) (mean ± SD) 200.9 ± 113.6 2 (5.1%) Anterior/Septal (n,%) 15 (38.5%) Inferior (n,%) 33 (84.6%) Lateral (n,%) 11 (28.2%) Apical (n,%) 3 (7.7%) Prior amiodarone (n,%) 17 (43.6%) ICD before ablation (n,%) 33 (84.6%) ICD after ablation (n,%) 4 (10.3%) CRT (n,%) 3 (7.7%) PCI (n,%) 28 (71.8%) CBAG (n,%) 9 (23.1%) Electrical storm at admission (n,%) 10 (25.6%) Table 1 – Baseline characteristics Clinical VTCL (ms) (mean ± SD) 376.8 ± 67.1 9 (23.1 %) Number of isthmuses identified via CT-scan 3.6 ± 1.8 4 (10.3 %) Transseptal access (n, %) 32 (82.1 %) Retro-aortic access (n, %) 5 (12.8 %) Both transseptal and retro-aortic access (n, %) 2 (5.1 %) Merging time (min) (mean ± SD) 9.5 ± 4.2 2 (5.1 %) Pre-ablation induction: Not done (n, %) 17 (43.6 %) Pre-ablation induction: Done but not inducible (n,%) 12 (30.8 %) Pre-ablation induction: Via PVS (n,%) 7 (17.9 %) Pre-ablation induction: Mechanical (n,%) 3 (7.7 %) Table 2 – Procedural characteristics Not inducible after isthmus ablation (n, %) 19.0 (48.7 %) Still inducible after isthmus ablation (n, %) 19.0 (48.7 %) No inducibility test performed after isthmus ablation (n, %) 1.0 (2.6 %) VT origin after isthmus ablation: prespecified isthmuses (n, %) 4 (21.1 %) VT origin after isthmus ablation: other than prespecified isthmuses (n, %) 15 (78.9 %) VT cycle length after ablation (ms) (mean ± SD) 300.1 ± 45.4 VT cycle length in cases originating from prespecified isthmuses (ms) (mean ± SD) 354 ± 44.8 VT cycle length in cases originating from other areas (ms) (mean ± SD) 285.7 ± 34.1 RF time for isthmus ablation (min) (mean ± SD) 35.2 ± 19.1 3 (7.7%) Additional RF time after isthmus ablation (min) (mean ± SD) 10.9 ± 8.0 3 (7.7%) Final inducibility (n, %) 3.0 (7.7%) Total RF time (min) (mean ± SD) 40.0 ± 21.4 3 (7.7 %) Procedural time (min) (mean ± SD) 196.5 ± 58.7 Fluoroscopy time (min) (mean ± SD) 20.8 ± 7.1 19 (48.7 %) AK dose (mGy) (mean ± SD) 108.9 ± 67.6 18 (46.2%) DAP (mGy/cm2) (mean ± SD) 14805.6 ± 17581.0 18 (46.2%) Table 3 – Ablation outcomes Figure 1 -- Flow chart 12 82.0% (66.0-91.0) 24 76.9% (60.3-87.3) 48 61.9% (44.1-75.6) Figure 2 - Kaplan Meier curve of survival free of VT in the patient cohort (n = 39) Figure 3 - Central Figure - Description of the CT-guided ablation workflow (ischemic VT, inferior scar). Every patient underwent a cardiac CT with segmentation using the inHeart software. CT channels were defined a priori based on wall thickness heterogeneity (wall thickness < 5 mm illustrated in red) illustrated as green arrows on the central image. The procedure starts with a quick merging step, using the CS, PA and LV volumes. The ablation target is then defined according to the prespecified isthmii in the EAM system (panel 2) and anatomical ablation based on these isthmii is performed (panel 3). Inducibility is tested after this step, and further ablation is performed if still inducible. Information & Authors Information Version history V1 Version 1 18 February 2025 Peer review timeline Published Journal of Cardiovascular Electrophysiology Version of Record 26 May 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Journal of Cardiovascular Electrophysiology Keyword clinical: catheter ablation – ventricular tachycardia Authors Affiliations Benjamin Sacristan 0009-0002-6139-0340 [email protected] Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Hubert Cochet Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Benjamin Bouyer 0000-0002-7702-7610 Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Romain Tixier Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Josselin Duchateau Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Nicolas Derval Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Thomas Pambrun Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Marine Arnaud Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Jan Charton Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Geoffroy Ditac Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Allan Plant Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author John Fitzgerald Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Soumaya Sdiri-Cheniti Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Laurens Verhaege Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Michel Montaudon Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Mélèze Hocini Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Michel Haissaguerre Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Maxime Sermesant Centre Inria d'Universite Cote d'Azur View all articles by this author pierre jais Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Frederic Sacher Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique View all articles by this author Metrics & Citations Metrics Article Usage 309 views 264 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Benjamin Sacristan, Hubert Cochet, Benjamin Bouyer, et al. 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