Ablation of Stable VTs Versus Substrate Ablation in Ischemic Cardiomyopathy: The VISTA Randomized Multicenter Trial
Luigi Di Biase1, J David Burkhardt2, Dhanujaya Lakkireddy3
1Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine, at Montefiore Hospital, Bronx, New York; Department of Biomedical Engineering, University of Texas, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
Insights
Substrate-based ablation significantly reduces ventricular tachycardia (VT) recurrence compared to clinical VT ablation in patients with ischemic cardiomyopathy. This extensive approach improves long-term outcomes and reduces rehospitalizations.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Catheter ablation is used to manage ventricular tachycardia (VT) in patients with ischemic cardiomyopathy.
- The optimal catheter ablation strategy for VT remains unclear.
Purpose of the Study:
- To compare the efficacy of substrate-based ablation versus clinical VT ablation for VT recurrence.
- To evaluate secondary endpoints including complications, mortality, and rehospitalizations.
Main Methods:
- Randomized trial comparing substrate-based ablation (targeting abnormal electrograms) with clinical VT ablation (targeting only clinical VTs).
- Included patients with ischemic cardiomyopathy and hemodynamically tolerated VT.
- Primary endpoint was VT recurrence; secondary endpoints included complications, mortality, and rehospitalizations at 12 months.
Main Results:
- VT recurrence was significantly lower in the substrate-based ablation group (15.5%) compared to the clinical VT ablation group (48.3%).
- Substrate-based ablation led to fewer patients requiring antiarrhythmic drugs and rehospitalizations.
- Mortality rates were similar, but the combined incidence of rehospitalization and mortality was lower with substrate-based ablation.
Conclusions:
- Extensive substrate-based ablation is superior to targeting only clinical VTs for managing VT in ischemic cardiomyopathy.
- Substrate-based ablation offers improved long-term success rates and reduced adverse events.
Background:
Catheter ablation reduces ventricular tachycardia (VT) recurrence and implantable cardioverter defibrillator shocks in patients with VT and ischemic cardiomyopathy. The most effective catheter ablation technique is unknown.
Objectives:
This study determined rates of VT recurrence in patients undergoing ablation limited to clinical VT along with mappable VTs ("clinical ablation") versus substrate-based ablation.
Methods:
Subjects with ischemic cardiomyopathy and hemodynamically tolerated VT were randomized to clinical ablation (n = 60) versus substrate-based ablation that targeted all "abnormal" electrograms in the scar (n = 58). Primary endpoint was recurrence of VT. Secondary endpoints included periprocedural complications, 12-month mortality, and rehospitalizations.
Results:
At 12-month follow-up, 9 (15.5%) and 29 (48.3%) patients had VT recurrence in substrate-based and clinical VT ablation groups, respectively (log-rank p < 0.001). More patients undergoing clinical VT ablation (58%) were on antiarrhythmic drugs after ablation versus substrate-based ablation (12%; p < 0.001). Seven (12%) patients with substrate ablation and 19 (32%) with clinical ablation required rehospitalization (p = 0.014). Overall 12-month mortality was 11.9%; 8.6% in substrate ablation and 15.0% in clinical ablation groups, respectively (log-rank p = 0.21). Combined incidence of rehospitalization and mortality was significantly lower with substrate ablation (p = 0.003). Periprocedural complications were similar in both groups (p = 0.61).
Conclusions:
An extensive substrate-based ablation approach is superior to ablation targeting only clinical and stable VTs in patients with ischemic cardiomyopathy presenting with tolerated VT. (Ablation of Clinical Ventricular Tachycardia Versus Addition of Substrate Ablation on the Long Term Success Rate of VT Ablation (VISTA); NCT01045668).
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