Ventricular tachycardia ablation plus subcutaneous ICD implant appears beneficial
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Key takeaways:
- Patients with scar-related ventricular tachycardia (VT) who received VT ablation plus a subcutaneous ICD had fewer shocks than those with a transvenous ICD.
- The difference was driven by appropriate shocks.
In adults with scar-related ventricular tachycardia, a strategy of ventricular tachycardia ablation plus implantation of a subcutaneous implantable cardioverter defibrillator led to better outcomes than use of a transvenous ICD, data show.
For the VTabl-SICD study, presented at Heart Rhythm 2023, researchers analyzed 32 patients with scar-related sustained ventricular tachycardia (VT) or ventricular fibrillation who underwent VT ablation using high-density electroanatomic mapping (Rhythmia HDx, Boston Scientific) and subsequent implantation of a subcutaneous ICD (Emblem S-ICD, Boston Scientific) and compared them with 64 propensity-score matched patients from the Ranolazine in High-Risk Patients with ICDs (RAID) trial who were implanted with a secondary prevention transvenous ICD and had similar clinical characteristics. For both groups, the mean age was 60 years and 18% were women.
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“These patients usually get a transvenous ICD, but those have disadvantages, including systemic infection, acceleration rates leading to inappropriate shocks, venous occlusions and slow heartbeat,” Ilan Goldenberg, MD, professor of medicine and director of the Clinical Cardiovascular Research Center at the University of Rochester Medical Center, told Healio. “The subcutaneous ICD can take care of the slow beaters. On the other hand, VT ablation was shown to be highly successful at reducing the risk of scar-related VT, especially the VT burden and the slow VTs. In this study, we hypothesized that a combined strategy of VT ablation subsequently followed by S-ICD implantation in patients who present with scar-related VT would be associated with a significant reduction in therapy burden and improvement in clinical outcomes.”
At 2 years, the rate of any ICD therapy was lower in the VT ablation S-ICD group than in the transvenous ICD group (32% vs. 73%; HR = 0.2; 95% CI, 0.09-0.43; log-rank P < .001), driven by an 87% reduction in appropriate ICD therapy (HR = 0.13; 95% CI, 0.05-0.36; log-rank P < .001), the researchers found.
There were no cases of antitachycardia pacing in the VT ablation S-ICD group compared with 60% in the transvenous ICD group, yet the VT ablation S-ICD group did not have an increase in untreated therapy, Goldenberg told Healio.
Risk for CV readmission or death was numerically lower in the VT ablation S-ICD group (HR = 0.73; P = .09), according to the researchers.
“We believe that ... in patients who present with scar-related VT, VT ablation plus a subcutaneous ICD appears to be superior to conventional transvenous ICD implantation for the secondary prevention of sudden cardiac death, reducing any ICD therapy, especially appropriate ICD shocks, and iterations of [antitachycardia pacing],” Goldenberg told Healio. “These findings are convincing enough that today, when a patient presents with sustained VT, they should be treated aggressively with VT ablation for the arrhythmia, and then this should possibly be followed by subcutaneous ICD implantation to reduce the risk for device-related complications.”
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Goldenberg I, et al. Abstract PO-03-216. Presented at: Heart Rhythm 2023; May 19-21, 2023; New Orleans (hybrid meeting).
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