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Ablation as First-Line Treatment in Tolerated VT and LVEF >35%
Quick Takes
- Post-MI patients with an LVEF >35% who presented with hemodynamically tolerated VT, and who were noninducible for any VT after ablation, had an excellent long-term outcome.
- Overall, these data suggest that in post-MI patients with tolerated VTs and preserved EF, arrhythmic prognosis is excellent after successful functional substrate ablation.
- Patients with poor cardiac function, with nontolerated VT, or who remain inducible for VT, have a more serious electrophysiological substrate that is not reliably controllable by ablation and should receive ICDs according to current guidelines.
Study Questions:
What are the outcomes of patients referred for ventricular tachycardia (VT) ablation according to left ventricular ejection fraction (LVEF), tolerance of VT, and acute ablation outcome?
Methods:
The investigators included post–myocardial infarction (MI) patients without prior implantable cardioverter-defibrillator (ICD) undergoing VT ablation at a single center between 2009 and 2022. Patients who presented with tolerated VT and who had an LVEF >35% were offered catheter ablation as first-line therapy. ICD implantation was offered to all patients but was subject to shared decision according to clinical presentation, LVEF, and ablation outcome. Patients were followed 3 and 6 months after the procedure and every 6 months thereafter for VT recurrence, antiarrhythmic drug use at latest follow-up, all-cause mortality, and sudden cardiac death (SCD). Categorical variables are expressed as number and percentage and compared with the chi-square or Fisher exact test. Survival analysis was performed using Kaplan-Meier survival curves.
Results:
Eighty-six patients (mean age 69 ± 9 years, 84% male, mean LVEF 41 ± 9%) underwent VT ablation. In 66 patients, LVEF was >35%, of whom 51 had tolerated VT. Of these 51 patients, 37 (73%) were rendered noninducible. In 5 of 37 noninducible and in 11 of 14 inducible patients, an ICD was implanted. During a median follow-up of 40 months (Q1-Q3: 24-70 months), 10 of 86 patients had VT recurrence. The overall mortality was 27%, and one patient with an ICD died suddenly. Among the 37 patients (none on antiarrhythmic drugs) with LVEF >35%, tolerated VT, and noninducibility, no SCD or VT recurrence occurred. Among the 14 patients with LVEF >35%, tolerated VT, and inducibility after ablation, no SCD occurred, but VT recurred in 29%.
Conclusions:
The authors report that post-MI patients with LVEF >35%, tolerated VT, and noninducibility after ablation have an excellent prognosis.
Perspective:
This study reports that post-MI patients with an LVEF >35% who presented with hemodynamically tolerated VT, who were noninducible for any VT after ablation, had an excellent long-term outcome. Furthermore, none had VT recurrence or experienced SCD during a median follow-up of 3 years, despite only 14% receiving an ICD. Overall, these data suggest that in post-MI patients with tolerated VTs and preserved EF, arrhythmic prognosis is excellent after successful functional substrate ablation. In contrast, patients with poor cardiac function, with nontolerated VT, or who remain inducible for VT, have a more serious electrophysiological substrate that is not reliably controllable by ablation and should receive ICDs according to current guidelines.
Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Catheter Ablation, Death, Sudden, Cardiac, Defibrillators, Implantable, Tachycardia, Ventricular
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