Radio-frequency Ablation as Primary Management of Well-Tolerated Sustained Monomorphic Ventricular Tachycardia in Patients With Structural Heart Disease and Left Ventricular Ejection Fraction Over 30%

Feb 25, 2014
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Authors:
Maury P, Baratto F, Zeppenfeld K, et al.
Citation:
Eur Heart J 2014;Feb 16:[Epub ahead of print].
Summary By:
Thomas C. Crawford, MD, FACC

Study Questions:

Is it safe for patients with well-tolerated sustained monomorphic ventricular tachycardia (SMVT) and left ventricular ejection fraction (LVEF) >30% to undergo primary VT ablation and not to receive a “back-up” implantable cardioverter-defibrillator (ICD)?

Methods:

One hundred and sixty-six patients with structural heart disease (SHD), LVEF >30%, and well-tolerated SMVT (no syncope) underwent primary radiofrequency ablation without ICD implantation at eight European centers. Three hundred seventy-eight similar patients were implanted with an ICD during the same period and served as a control group.

Results:

There were 139 men (84%) with mean age 62 ± 15 years and mean LVEF of 50% ± 10%. Fifty-five percent had ischemic heart disease, 19% nonischemic cardiomyopathy, and 12% arrhythmogenic right ventricular cardiomyopathy. All-cause mortality was 12% (20 patients) over a mean follow-up of 32 ± 27 months. Eight patients (40%) died from noncardiovascular causes, eight (40%) died from nonarrhythmic cardiovascular causes, and four (20%) died suddenly (2.4% of the population). All-cause mortality in the control group was 12%. Twenty-seven patients (16%) had a nonfatal recurrence at a median time of 5 months, while 20 patients (12%) required an ICD, of whom four died (20%).

Conclusions:

Patients with well-tolerated SMVT, SHD, and LVEF >30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death, and recurrences were generally nonfatal.

Perspective:

In this hypothesis-generating retrospective cohort study, the authors suggest that a strategy of primary VT ablation without back-up ICD is reasonable in patients with well-tolerated VT and EF >30%. It may be that a group at low risk of sudden death may be identified, but a rigorous randomized trial with strict entry criteria would be necessary to entertain such an approach.

Keywords: Arrhythmogenic Right Ventricular Dysplasia, Myocardial Ischemia, Tachycardia, Ventricular, Stroke Volume, Death, Sudden, Cardiac, Defibrillators, Implantable


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