Endocardial unipolar voltage mapping to identify epicardial substrate in arrhythmogenic right ventricular cardiomyopathy/dysplasia

The risk and success of epicardial substrate ablation for ventricular tachycardia (VT) support the value of techniques identifying the epicardial substrate with endocardial mapping.The purpose of this study was to test the hypothesis that endocardial unipolar voltage mapping in patients with right ventricular (RV) VT and preserved endocardial bipolar voltage abnormalities might identify the extent of epicardial bipolar voltage abnormality.Using a cutoff of < 5.5 mV for normal endocardial unipolar voltage derived from 8 control patients without structural heart disease, 10 patients with known ARVC/D (group 1, retrospective) and 13 patients with RV VT (group 2, prospective) with modest or no endocardial bipolar voltage abnormalities underwent detailed endocardial and epicardial mapping.The area of epicardial unipolar voltage abnormality in all 10 group 1 patients with ARVC/D (62 ± 21 cm²) and in 9 of the 13 group 2 patients (8 with criteria for ARVC/D) (53 ± 21 cm²) was on average three times more extensive than the endocardial bipolar abnormality and correlated (r = 0.63, P <.05 and r = 0.81, P <.008, respectively) with the larger area epicardial bipolar abnormality with respect to size (group 1: 82 ± 22 cm²; group 2: 68 ± 41 cm²) and location. In the remaining 4 group 2 patients and 3 additional reference patients without structural heart disease, endocardial bipolar, endocardial unipolar, and, as predicted, epicardial bipolar voltage all were normal.Endocardial unipolar mapping with cutoff of 5.5 mV identifies more extensive areas of epicardial bipolar signal abnormalities in patients with ARVC/D and limited endocardial VT substrate.