Ventricular Tachycardia Ablation vs. Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease - VANISH

Description:

The goal of the trial was to evaluate ventricular tachycardia ablation versus escalation of antiarrhythmic drug therapy among individuals with an ischemic cardiomyopathy and implantable cardioverter-defibrillator (ICD) who had ventricular tachycardia despite antiarrhythmic drug therapy.

Contribution to the Literature: The VANISH trial showed that ventricular tachycardia ablation was superior to escalation of drug therapy at reducing death, ventricular tachycardia storm, or ICD shocks.

Study Design

  • Randomized
  • Parallel

Patients with ventricular tachycardia despite antiarrhythmic drug therapy were randomized to ventricular tachycardia catheter ablation (n = 132) versus escalation of drug therapy (n = 127). In the escalation of drug therapy group, patients received amiodarone (at least 300 mg) if another agent had been used previously or mexiletine.

  • Total number of enrollees: 259
  • Duration of follow-up: 27.9 months
  • Patient age (mean): 69 years
  • Percentage female (mean): 7%
  • Percentage diabetics (mean): 30%

Inclusion criteria:

  • Prior myocardial infarction
  • Ischemic cardiomyopathy and ICD
  • Persistent ventricular tachycardia despite antiarrhythmic drug therapy

Exclusion criteria:

  • Acute coronary syndrome (e.g., acute thrombus or dynamic ST-segment changes on electrocardiogram) or another reversible cause of ventricular tachycardia (e.g., electrolyte abnormalities, drug-induced arrhythmia)
  • Ineligible to take amiodarone (e.g., active hepatitis, current hyperthyroidism, pulmonary fibrosis, known allergy)
  • Ineligible for ablation (e.g., protruding left ventricular thrombus, or implanted mechanical aortic and mitral valves)
  • Renal failure (creatinine clearance <15 ml/min)
  • New York Heart Association class IV heart failure or Canadian Cardiovascular Society class IV angina
  • Recent ST-elevation myocardial infarction (<1 month)
  • Recent coronary bypass surgery (<3 months) or percutaneous coronary intervention (<1 month)
  • Prior ablation for ventricular tachycardia
  • Systemic illness likely to limit survival to <1 year

Principal Findings:

The primary outcome of death, ≥3 episodes of ventricular tachycardia within 24 hours, or appropriate ICD shock occurred in 59.1% of the catheter ablation group versus 68.5% of the escalated drug therapy group (p = 0.04).

Secondary outcomes: In the ablation group, there were two cardiac perforations and three major bleeds. In the escalated drug therapy group, there were two deaths from pulmonary toxicity and one death from hepatic dysfunction.

Interpretation:

Among individuals with prior myocardial infarction and ischemic cardiomyopathy with persistent episodes of ventricular tachycardia, catheter ablation of ventricular tachycardia was superior to escalation of antiarrhythmic drug therapy. There were important toxicities, which occurred in the escalated drug therapy group.

References:

Sapp JL, Wells GA, Parkash R, et al. Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs. N Engl J Med 2016;May 5:[Epub ahead of print].

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Acute Coronary Syndrome, Amiodarone, Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Cardiomyopathies, Catheter Ablation, Defibrillators, Implantable, Heart Failure, Mexiletine, Myocardial Infarction, Secondary Prevention, Shock, Tachycardia, Ventricular


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