First-line ablation of ventricular tachycardia in ischemic cardiomyopathy: stratification of outcomes by left
David F Briceño1, Jorge Romero1, Kavisha Patel1
1Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
Insights
First-line catheter ablation for ventricular tachycardia (VT) in ischemic cardiomyopathy (ICM) reduces appropriate implantable cardioverter-defibrillator therapies. This benefit is primarily seen in patients with moderately depressed left ventricular ejection fraction (LVEF).
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Ischemic cardiomyopathy (ICM) is a common cause of ventricular tachycardia (VT) and ventricular fibrillation (VF).
- Catheter ablation is an established treatment for drug-resistant VT/VF, but its role as a first-line therapy in ICM requires further clarification.
- Left ventricular ejection fraction (LVEF) is a key prognostic factor in patients with heart failure and VT/VF.
Purpose of the Study:
- To evaluate the effectiveness of first-line catheter ablation compared to medical therapy for VT/VF in patients with ICM.
- To stratify outcomes based on LVEF to identify patient subgroups that benefit most from ablation.
Main Methods:
- A meta-analysis of four randomized controlled trials (RCTs) involving 505 patients with VT and ICM was conducted.
- Outcomes, including survival free from appropriate implantable cardioverter-defibrillator (ICD) therapies and composite endpoints, were analyzed.
- Risk estimates and 95% confidence intervals (CI) were calculated to assess treatment effects.
Main Results:
- First-line catheter ablation significantly reduced appropriate ICD therapies compared to medical management in all patients (RR 0.70, 95% CI 0.56-0.86).
- A significant benefit was observed in patients with moderately depressed LVEF (>30-50%), showing a reduction in VT/VF and appropriate ICD therapies (HR 0.52, 95% CI 0.36-0.76).
- No significant difference was found in patients with severely depressed LVEF (≤30%) (HR 0.56, 95% CI 0.24-1.32).
Conclusions:
- First-line catheter ablation for VT in ICM patients lowers appropriate ICD therapies without impacting overall mortality.
- The positive impact of first-line ablation is predominantly observed in patients with moderately depressed LVEF (>30-50%).
- Further research may refine patient selection for ablation based on LVEF in ICM.
Purpose:
First-line catheter ablation of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with ischemic cardiomyopathy (ICM) has been associated with improved outcomes; however, most benefit seems to be in patients with moderately depressed left ventricular ejection fraction (LVEF). Herein, outcomes were stratified based on LVEF.
Methods:
A meta-analysis of randomized controlled trials (RCTs) evaluating first-line ablation versus medical therapy in patients with VT and ICM was performed. Risk estimates and 95% confidence intervals (CI) were measured.
Results:
Four RCTs with a total of 505 patients (mean age 66 ± 9 years, 89% male, 80% with previous revascularization) were included. Mean LVEF was 35 ± 8%. At a mean follow-up of 24 ± 9 months, a significant benefit in survival-free from appropriate implantable cardioverter-defibrillator (ICD) therapies was observed in all patients undergoing first-line catheter ablation compared with medical management (RR 0.70, 95% CI 0.56-0.86). In patients with moderately depressed LVEF (> 30-50%), first-line VT ablation was associated with a statistically significant reduction in the composite endpoint of survival free from VT/VF and appropriate ICD therapies (HR 0.52, 95% CI 0.36-0.76), whereas there was no difference in patients with severely depressed LVEF (≤30%) (HR 0.56, 95% CI 0.24-1.32). Funnel plots did not show asymmetry suggesting lack of bias.
Conclusions:
Patients with ICM and VT undergoing first-line ablation have a significantly lower rate of appropriate ICD therapies without a mortality difference compared with patients receiving an initial approach based on medical therapy. The beneficial effect of a first-line ablation approach was only observed in patients with moderately depressed LVEF (> 30-50%).
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