Ventricular arrhythmias (VAs) in patients with nonischemic cardiomyopathy (NICM) can present as ventricular premature depolarizations (VPDs), monomorphic ventricular tachycardia (VT), and polymorphic VT/ventricular fibrillation. The clinical presentation of VAs depends on hemodynamic stability during the arrhythmia, and includes palpitations, syncope, and death. Although implantable cardioverter-defibrillators (ICDs) are the mainstay of therapy to prevent sudden cardiac death, VAs can lead to syncope and ICD shocks, and can also be responsible for nonresponse to cardiac resynchronization therapy. In rare cases of NICM and frequent VPDs, the possibility of VPD-induced cardiomyopathy should be explored. Catheter ablation has evolved as an important management strategy for VAs. However, in the setting of NICM, epicardial mapping and ablation has been shown to be an important adjunctive measure to endocardial ablation. This article reviews the indications, technique, and evidence for epicardial ablation in the setting of NICM. Specific disease states, such as hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular dysplasia (ARVD), valvular cardiomyopathy, and cardiac sarcoidosis, may also have indications for epicardial ablation (with different success rates), and are not addressed in detail in this review.
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