Ventricular Tachycardia Ablation in Coronary Heart Disease - VTACH

Description:

The goal of this trial was to evaluate a strategy of catheter ablation for ventricular tachycardia (VT) plus implantable cardioverter defibrillator (ICD) compared with ICD alone.

Hypothesis:

Catheter ablation plus ICD would be superior at reducing VT recurrence.

Study Design

  • Randomized
  • Stratified

Patients Enrolled: 110
Mean Follow Up: 2 years
Mean Patient Age: 66 years
Female: 7%
Mean Ejection Fraction: 34%

Patient Populations:

  • Patients 18-80 years of age with history of stable VT, myocardial infarction, and LV systolic dysfunction (EF ≤50%)

Exclusions:

  • Myocardial infarction within the last month
  • Cardiac surgery within the last 2 months
  • LV thrombus
  • Valvular heart disease or mechanical heart valve
  • Unstable angina
  • Incessant VT
  • Bundle branch re-entry tachycardia
  • Contraindication to heparin
  • Renal insufficiency
  • Advanced heart failure
  • Expected survival <12>

Primary Endpoints:

  • Time to first recurrence of VT or VF

Secondary Endpoints:

  • Survival free from severe clinical events, defined as death, syncope, hospital readmission, and VT storm
  • Number of appropriate device therapies (antitachycardia pacing or shock)
  • Quality of life

Drug/Procedures Used:

Patients undergoing implantation of an ICD had an electrophysiologic study to induce VT. They were then randomized to VT catheter ablation plus ICD (n = 54) versus ICD alone (n = 56).

Principal Findings:

Overall, 110 patients were randomized. The mean age was 66 years, 7% were women, mean left ventricular ejection fraction (LVEF) was 34%, mean time since last myocardial infarction was 12.9 years, and mean follow-up was 22.5 months. Successful ablation was reported in 52% of patients.

The primary outcome, median time to first VT or ventricular fibrillation (VF) was 18.6 months in the ablation group versus 5.9 months in the control group (p = 0.045). The 24-month event-free survival from VT or VF was 47% versus 29% (p = 0.045), freedom from death was 92% versus 91% (p = 0.68), and the mean appropriate shocks per patient per year was 0.6 versus 3.4 (p = 0.018), respectively, for ablation versus control.

Considering freedom from VT or VF, patients with less severe LV dysfunction (EF >30%) appeared to benefit more from catheter ablation (p = 0.016) than patients with severe LV dysfunction (EF ≤30%) (p = 0.76).

Interpretation:

Among patients with a history of stable VT eligible for ICD implantation, catheter ablation of VT at the time of the procedure appeared to be beneficial. Prophylactic catheter ablation reduced the time to first recurrence of VT or VF and improved freedom from VT or VF.

This is a technically demanding procedure, as evidenced by a success rate of approximately 50%. This will limit the generalizability of this procedure into the community setting; however, prophylactic catheter ablation may be appropriate for some carefully selected individuals. This procedure deserves further study.

References:

Kuck KH, Schaumann A, Eckardt L, et al. Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial. Lancet 2010;375:31-40.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Myocardial Infarction, Tachycardia, Ventricular, Follow-Up Studies, Ventricular Fibrillation, Heart Failure, Disease-Free Survival, Stroke Volume, Electrophysiologic Techniques, Cardiac, Catheter Ablation, Defibrillators, Implantable


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