Ventricular Tachycardia and ICD Therapy Burden With Catheter Ablation Versus Escalated Antiarrhythmic Drug Therapy.

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.
Competing Interests: Funding Support and Author Disclosures The VANISH trial was funded by the Canadian Institutes of Health Research, with additional financial support from St. Jude Medical and Biosense Webster. Dr Healey has served as a consultant for and has received speaker fees and research grants from Medtronic, Boston Scientific, and Abbott. Dr Nault has received honoraria from Biosense Webster, Servier, BMS-Pfizer, and Bayer. Dr Essebag has received a Fonds de recherche du Québec clinical research scholar award; and has received honoraria from Medtronic, Abbott, and Biosense Webster. Dr Parkash has received research funding from Abbott, Medtronic, and Novartis. Dr Sapp has received research funding from Biosense Webster and Abbott; and has received speaker fees or consulting honoraria from Medtronic, Abbott, Varian, and Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)