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Peter Leong-Sit, MD MSc FRCPC FHRS Associate Professor of Medicine, Western University London Heart Rhythm Program September 13, 2019

CON: VT Ablation Should be First Line Therapy Before ICD Implant in Patients Presenting with Monomorphic VT

Disclosures

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The Bully and the Underdog

Sensei Dr. William Sauer and the powerful Cobra Kai Brigham & Women’s EP Team Me – just trying to fight for the truth

Point #1: Risk of Sudden Death

• Structural heart disease + ventricular

tachycardia = risk of sudden death

• Old lesson from AVID, CIDS, and CASH
• RCTs of 2* prevention with VT/VF

AVID Investigators. NEJM 1997; 337:1576-83. Connolly et al. Circ 2000; 101:1297-302. Kuck et al. Circ 2000; 102:748-54.

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Connolly et al. Eur Heart J 2000; 21:2071-8.

AVID CIDS & CASH - Patients

AVID CIDS & CASH - Meta-analysis

Connolly et al. Eur Heart J 2000; 21:2071-8.

Prognosis with LVEF 35-50%

• 5 year all-cause mortality

– LVEF < 35%: 40-45% – LVEF 35-50%: 20-25%

• Hence, despite a better prognosis, a

population with structural heart disease and VT still has substantial mortality

Connolly et al. Eur Heart J 2000; 21:2071-8.

Point #1

Therefore, we have established that patients with structural heart disease and monomorphic VT, even with an LVEF above 35%, carries a substantial risk

• f mortality

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Point #2: ICD’s unequivocally work!

SCD-HeFT: Ischemic and NICM MADIT-II: Ischemic CM

Moss AJ et al. NEJM 2002; 346:877-83 Bardy GH et al. NEJM 2005; 352:225-37

ICDs work in those with MMVT

Connolly et al. Eur Heart J 2000; 21:2071-8.

CIDS, AVID, & CASH – Meta-analysis on Mortality

Why not an ICD? Painless Rx

• VT can be

terminated the majority of the time painlessly

Wathen et al. PainFree II. Circ 2004; 110:2591-6

Inappropriate Shocks are Low

Sedlacek et al. MADIT-RIT. JCE 2015;26:424-33

9/14/2019 4 Point #2

Therefore, we have established that ICDs are effective tools to reduced mortality and can often do so in a painless manner

“They fixed my breaks, I don’t need my seatbelt.”

Always wear your seatbelt. (I’ll take the ICD please!)

Point #3: We aren`t perfect at VT ablation

HR 0.47, 0.24-0.88 p=0.016

Kuck KH et al. Lancet 2010;375:31-40

VTACH Trial

• N=107 with stable VT

and prior MI

• Randomized to ICD

with VT ablation vs ICD alone

Sapp J et al. NEJM 2016;375:111-21

• VANISH Trial

– N=259 patients with ischemic CM and MMVT failing drugs – Randomized to drug escalation vs ablation

This is a reproducible finding

9/14/2019 5 Amiodarone is tough to beat

Ablation is better than increasing amiodarone if amiodarone failed BUT, amiodarone first line was just as good as ablation

Sapp J et al. NEJM 2016;375:111-21

Network Meta-analysis

• IschCM VT – 16 RCTs (11 manuscripts, 3 abstracts)

Leong-Sit et al. HRS 2017.

Cautionary Tale: Amiodarone

Bardy GH et al. NEJM 2005; 352:225-37

Your VT will be cured!

When something seems too good to be true.... Magic VT Ablation Beans

9/14/2019 6 Point #3

VT ablation techniques are imperfect and give rise to variable results.

In summary…

1) There’s a established risk of sudden death in patients with VT and structural heart disease 2) ICDs are reliable at reducing sudden death, often with painless therapies 3) VT ablation is imperfect and techniques and results are variable

Rebuttal ACC/AHA/HRS Guidelines

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When Shown Results Like This:

“Well, their results are poor because we just know how to do this ablation better.” Secret in EP: We aren’t Perfect at VT ablation (Except for our Me... Except for our Lab...)

VT Ablation is So Variable... My centre

• Dr. Leong-Sit

UPenn

• Dr. Roberts

UCSF

The truth is VT ablation is variable

9/14/2019 8 ICDs are much more standardized

Big Mac in New York Big Mac in Los Angeles

Point #4: What about non-ischemic VTs?

• Cardiac sarcoid with MMVT ablation
• N=5 cohort studies, n=83 patients
• Mean/median follow-up: 20-27 months
• At least 1 VT recurrence in 45/83 (54%)

Papageorgiou et al. Europace 2018;20:682-91.

ARVC VT Ablation

• N=110 with ARVC and >3 VT episodes
• N=75 underwent ablation
• At 3 years, ablation 35% vs drugs 28% VT-free
• Overall, 56% were VT-free after last ablation

procedure

Mahida S et al. Heart Rhythm 2019;16:536-43.

Point #4

VT ablation is likely even less robust in the non-ischemic population such as cardiac sarcoid or arrhythmogenic cardiomyopathy.

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In summary…

1) There’s a established risk of sudden death in patients with VT and structural heart disease 2) ICDs are reliable at reducing sudden death, often with painless therapies 3) VT ablation is imperfect and techniques and results are variable 4) We’re probably even worse at non-ischemic VT ablation

We must therefore conclude:

VT Ablation Should NOT be First Line Therapy Before ICD Implant in Patients Presenting with Monomorphic VT

While VT ablation, especially in expert centres, may have a good role in VT reduction...

Thank You

• Dr. Sauer
• Dr. Leong-Sit