SLIDE 12 8/29/2016 12
Role of Early Prophylactic Catheter VT Ablation
N=98, 1/2008-4/2009, with VT and SHD:
- 58% in VT storm and 67% on high dose
amiodarone. Early referral (N=36) Late referral (N=62): ≥ 2 episodes of VT, separated by >1 month In Kaplan–Meier analysis, the early referral group had superior 1-year VT free survival (P=0.01).
Early referral Late referral
Ischemic 63% Nonischemic 37%
Frankel DS. J Cardiovasc Electrophysiol, 2011; 22:1123. P=0.01 (1) <30 days (2) 30 days-12 months (3) >12 months Dinov B. Circ Arrhythm Electrophysiol. 2014;7:1144 HR 2 vs 1=1.85; p=0.009 HR 3 vs 1=2.04; p=0.001
N=300 cath abl of sustained VT.
- Group 1 (25%): <30 days after 1st VT
- Group 2 (28%): 30 days-12 months
- Group 1 (47%): >12 months
In Kaplan-Meier curves of VT-free survival, cath abl within 30 days after 1st VT event is associated with improved acute and long-term success.
Ischemic 68% Nonischemic 32%
Other Clinical Trials in VT Catheter Ablations
- ASPIRE: Early Ablation Therapy for the Treatment of Ischemic Ventricular
Tachycardia in Patients With Implantable Cardioverter Defibrillators
– stopped enrollment
- STRATUM-VT: Stepwise AppRoAch To sUbstrate Modification for Ventricular
Tachycardia
– stopped enrollment
- STAR-VT: Substrate Targeted Ablation using the FlexAbility™ Ablation Catheter
System for the Reduction of Ventricular Tachycardia
– prophylactic scar-based VT ablation (both ischemic and non-ischemic) – stopped enrollment
- VANISH: Ventricular Tachycardia Ablation or Escalated Drug Therapy
– significantly lower rate of the composite outcome of death, VT storm, or appropriate ICD shock in patients undergoing catheter ablation than those receiving an escalation in antiarrhythmic drug therapy
- PARTITA: Does Timing of VT Ablation Affect Prognosis in Patients With an
Implantable Cardioverter-defibrillator?
VT Ablation 2016: Indications and Expected Outcomes
- Persistent inducibility is associated with VT recurrence and poor long-term results
in both NIDCM and ICM. A substrate-based, extensive ablation strategy is associated with improved outcomes.
- Post-infarction VTs are often associated with a relatively “stable” substrate.
Catheter ablation for post-infarct VT is becoming more mainstream and not limited to a “last-resort” strategy.
- NIDCM consists of a heterogeneous group of conditions with unknown factors
leading to modification of arrhythmia substrate over time. Disease/scar progression is the rule. However, incomplete ablation is the most common finding, strongly suggesting the need for more extensive ablation.
- Successful VT ablation has been associated with an mortality benefit with an
improved transplant-free survival in those without VT recurrence
- Early intervention and a “substrate ablation-first” approach may be preferable
compared to antiarrhythmic drug use and the standard VT induction protocol.
- Evolving with expanded and specific indications for VT ablations that include (1)
PVCs induced LV dysfunction, (2) Brugada syndrome with electrical storms, (3) short-coupled torsade de pointes, (4) annular-LVOT-epicardial arrhythmias
