Catheter ablation superior to antiarrhythmic drugs in VT with ischemic cardiomyopathy
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Key takeaways:
- Catheter ablation improved outcomes vs. antiarrhythmic drugs in patients with VT and ischemic cardiomyopathy.
- The results suggest catheter ablation should be a first-line therapy for this population.
CHICAGO — Catheter ablation improved outcomes compared with antiarrhythmic drug therapy in patients with ventricular tachycardia and ischemic cardiomyopathy, researchers reported at the American Heart Association Scientific Sessions.
“Patients who have ventricular tachycardia (VT) and shocks have worse outcomes than those who do not,” John L. Sapp, MD, FRCPC, FHRS, FCHRS, clinical cardiac electrophysiologist at the Queen Elizabeth II Health Sciences Centre and assistant dean of clinical research and professor of medicine at Dalhousie University in Halifax, Nova Scotia, Canada, said at a press conference. “So, sometimes we need to suppress VT. We have two methods of doing this. One is ... catheter ablation. Another method is to use antiarrhythmic drugs. We have previously shown that if antiarrhythmic drugs aren’t working, it is better to go to catheter ablation than to be more aggressive with antiarrhythmic drugs. That was the VANISH trial. The VANISH2 trial is designed to answer the question of what should be the first-line therapy to suppress VT. We hypothesized that catheter ablation was better.”
For the VANISH2 trial, Sapp and colleagues randomly assigned 416 patients with prior MI, implantable cardioverter defibrillator and clinically significant VT — defined as VT storm, receipt of appropriate ICD shock or antitachycardia pacing, or sustained VT terminated by emergency treatment — to receive catheter ablation (mean age, 67.7 years; 95.1% men) or antiarrhythmic drug therapy (sotalol or amiodarone; mean age, 68.4 years; 92.5% men).
The primary outcome was a composite of all-cause death at any time during follow-up or VT storm, appropriate ICD shock or sustained VT treated by medical intervention after more than 14 days after randomization. Median follow-up was 4.2 years.
During the study period, a primary outcome event occurred in 50.7% of the catheter ablation group and 60.6% of the drug therapy group (HR = 0.75; 95% CI, 0.58-0.97; P = .03), Sapp said during the press conference.
Compared with drug therapy, catheter ablation reduced death by 16%, VT storm by 5%, appropriate ICD shock by 25% and VT emergency treatment by 74%, with the latter reaching statistical significance (HR = 0.26; 95% CI, 0.13-0.55), “although that was in relatively fewer patients,” he said.
At 30 days, two patients (1%) of the catheter ablation group died and 23 patients (11.3%) from that group had adverse events, according to the researchers.
In the drug therapy group, one patient (0.5%) died of pulmonary toxic effects attributable to the medication and 46 patients (21.6%) had nonfatal adverse events attributable to drug therapy, the researchers found.
“For patients who have had a prior heart attack and present with VT, and patients and clinicians feel we should suppress the VT, catheter ablation was more effective at suppressing the primary outcome than antiarrhythmic drugs,” Sapp said at the press conference.
In a discussant commentary at the press conference, Healio | Cardiology Today Editorial Board Member Andrea M. Russo, MD, FACC, FHRS, FAHA, director of the cardiac electrophysiology and arrhythmia service at Cooper Medical School of Rowan University in Camden, New Jersey, and past president of the Heart Rhythm Society, said VANISH2 “is a very important study. This may change the way we practice. We would assume that reducing the number of shocks improves quality of life, but that requires further investigation.”
She also said more study of this topic in women is necessary, as the trial enrolled very few women.
Sana M. Al-Khatib, MD, professor of medicine at Duke University School of Medicine, who moderated the press conference, said: “I am super excited about the results of the VANISH2 trial. I say this because for a long time, we have struggled with identifying the best treatment strategy for our patients with heart failure and cardiomyopathy who present with ICD shocks for ventricular tachycardia. The tradition has been to treat those patients with medications and to introduce catheter ablation late in the game, and I have always questioned that. Why can’t we intervene earlier so we can have an impact before the disease progresses? VANISH2 provides us with an interesting data to support that practice.”
Reference:
Perspective
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The VANISH2 trial is very interesting because it looked at a real-life scenario where patients are very sick and are getting therapy with medications that are most frequently used in patients with HF and VT, and they have had an ICD implanted. These patients present a big challenge.
This is the largest prospective trial that has ever been done on this question in a real-life scenario. The researchers wanted to potentially show a difference in mortality, which is very difficult because these patients have an ICD, so essentially most of the mortality benefit is already provided by the ICD. However, they showed a significant, very impressive, reduction in VT in the ablation group. Many of these patients were treated with amiodarone, which is the most powerful weapon we have for VT, but ablation was far superior.
These results don’t even apply to new technologies like pulsed field ablation, for which we are starting to get initial signals of potentially superior efficacy, which will be tested in future trials. But this trial shows we already have the evidence to support VT ablation in real-world patients for whom we have to choose between ablation and medication.
Even before this study, catheter ablation was a reasonable choice as first-line therapy. Antiarrhythmic drugs have very significant side effects, some of which are even potentially lethal in the case of amiodarone. For many patients, this is a pretty easy choice. This is another substantial piece of evidence that supports opting for ablation earlier than previously thought.
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Sapp JL, et al. LBS Session 02: Redefining arrhythmia treatment: Pushing boundaries. Presented at: American Heart Association Scientific Sessions; Nov. 16-18, 2024; Chicago.
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