Ventricular Tachycardia and ICD Therapy Burden With Catheter Ablation Versus Escalated Antiarrhythmic Drug Therapy
Michelle Samuel1, Jeff S Healey2, Isabelle Nault3
1Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
Insights
Catheter ablation significantly reduced ventricular tachycardia (VT) burden and implantable cardioverter-defibrillator (ICD) therapy compared to escalated antiarrhythmic drugs (AADs) in patients with prior myocardial infarction. This benefit was most pronounced in patients with amiodarone-refractory VT.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Interventions
Background:
- Catheter ablation is known to improve event-free survival for ventricular tachycardia (VT) in patients with prior myocardial infarction (MI) and antiarrhythmic drug (AAD)-refractory VT.
- However, the impact of ablation on the burden of recurrent VT and implantable cardioverter-defibrillator (ICD) therapy has not been fully investigated.
Purpose of the Study:
- To compare the burden of VT and ICD therapy between catheter ablation and escalated AAD therapy in patients with VT and prior MI.
- This comparison was conducted within the framework of the VANISH trial.
Main Methods:
- The VANISH trial randomized patients with prior MI and VT despite initial AAD therapy to either escalated AAD treatment or catheter ablation.
- VT burden was quantified by the total number of VT events requiring at least one appropriate ICD therapy.
- Appropriate ICD therapy burden included the total number of shocks or antitachycardia pacing (ATP) therapies delivered, analyzed using the Anderson-Gill recurrent event model.
Main Results:
- A total of 259 patients were enrolled, with 132 randomized to ablation and 129 to escalated AAD therapy.
- Over a median follow-up of 23.4 months, catheter ablation resulted in a 40% reduction in shock-treated VT events and a 39% reduction in appropriate shock burden compared to escalated AAD therapy (P < 0.05).
- Reductions in VT burden, ATP-treated VT events, and appropriate ATP burden were observed with ablation but were significant only in patients with amiodarone-refractory VT (P < 0.05).
Conclusions:
- Catheter ablation effectively reduces the burden of VT and appropriate ICD shocks compared to escalated AAD therapy in patients with prior MI and AAD-refractory VT.
- The reduction in VT and ICD therapy burden with ablation is particularly significant for patients with amiodarone-refractory VT.
Background:
Catheter ablation improves ventricular tachycardia (VT) event-free (time to event) survival in patients with antiarrhythmic drug (AAD)-refractory VT and previous myocardial infarction (MI). The effects of ablation on recurrent VT and implantable cardioverter-defibrillator (ICD) therapy (burden) have yet to be investigated.
Objectives:
This study sought to compare the VT and ICD therapy burden following treatment with either ablation or escalated AAD therapy among patients with VT and previous MI in the VANISH (Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in ISchemic Heart disease) trial.
Methods:
The VANISH trial randomized patients with previous MI and VT despite initial AAD therapy to either escalated AAD treatment or catheter ablation. VT burden was defined as the total number of VT events treated with ≥1 appropriate ICD therapy. Appropriate ICD therapy burden was defined as the total number of appropriate shocks or antitachycardia pacing therapies (ATPs) delivered. The Anderson-Gill recurrent event model was used to compare burden between the treatment arms.
Results:
Of the 259 enrolled patients (median age, 69.8 years; 7.0% women), 132 patients were randomized to ablation and 129 patients were randomized to escalated AAD therapy. Over 23.4 months of follow-up, ablation-treated patients had a 40% lower shock-treated VT event burden and a 39% lower appropriate shock burden compared with patients who received escalated AAD therapy (P <0.05 for all). A reduction in VT burden, ATP-treated VT event burden, and appropriate ATP burden among ablation patients was only demonstrated in the stratum of patients with amiodarone-refractory VT (P <0.05 for all).
Conclusions:
Among patients with AAD-refractory VT and a previous MI, catheter ablation reduced shock-treated VT event burden and appropriate shock burden compared with escalated AAD therapy. There was also lower VT burden, ATP-treated VT event burden, and appropriate ATP burden among ablation-treated patients; however, the effect was limited to patients with amiodarone-refractory VT.
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