First-line ablation of ventricular tachycardia in ischemic cardiomyopathy: stratification of outcomes by left ventricula
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First-line ablation of ventricular tachycardia in ischemic cardiomyopathy: stratification of outcomes by left ventricular function David F. Briceño 1 & Jorge Romero 1 & Kavisha Patel 1 & Wasla Liaqat 1 & Xiao-Dong Zhang 1 & Isabella Alviz 1 & Ruike Yang 1,2 & Daniel Rodriguez 1 & Dhanunjaya Lakkireddy 3 & Domenico Della Rocca 4 & Nicola Tarantino 1 & Rakesh Gopinathannair 3 & Andrea Natale 4 & Luigi Di Biase 1,4 Received: 25 August 2020 / Accepted: 1 November 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose First-line catheter ablation of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with ischemic cardiomyopathy (ICM) has been associated with improved outcomes; however, most benefit seems to be in patients with moderately depressed left ventricular ejection fraction (LVEF). Herein, outcomes were stratified based on LVEF. Methods A meta-analysis of randomized controlled trials (RCTs) evaluating first-line ablation versus medical therapy in patients with VT and ICM was performed. Risk estimates and 95% confidence intervals (CI) were measured. Results Four RCTs with a total of 505 patients (mean age 66 ± 9 years, 89% male, 80% with previous revascularization) were included. Mean LVEF was 35 ± 8%. At a mean follow-up of 24 ± 9 months, a significant benefit in survival-free from appropriate implantable cardioverter-defibrillator (ICD) therapies was observed in all patients undergoing first-line catheter ablation compared with medical management (RR 0.70, 95% CI 0.56–0.86). In patients with moderately depressed LVEF (> 30–50%), firstline VT ablation was associated with a statistically significant reduction in the composite endpoint of survival free from VT/VF and appropriate ICD therapies (HR 0.52, 95% CI 0.36–0.76), whereas there was no difference in patients with severely depressed LVEF (≤30%) (HR 0.56, 95% CI 0.24–1.32). Funnel plots did not show asymmetry suggesting lack of bias. Conclusions Patients with ICM and VT undergoing first-line ablation have a significantly lower rate of appropriate ICD therapies without a mortality difference compared with patients receiving an initial approach based on medical therapy. The beneficial effect of a first-line ablation approach was only observed in patients with moderately depressed LVEF (> 30–50%). Keywords Catheter ablation . Ventricular tachycardia . Ischemic cardiomyopathy . Heart failure
1 Introduction In patients with ischemic cardiomyopathy (ICM), ventricular tachycardia and ventricular fibrillation (VT/VF) typically originate from a relatively discrete portion of the myocardium, within or * Luigi Di Biase [email protected] 1
Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
2
Division of Cardiology, Department of Medicine, Henan Provincial People’s Hospital, Zhengzhou, China
3
Kansas City Heart Rhythm Institute, Overland Park, KS, USA
4
Texas Cardiac Arrhythmia Institute, St. David’s
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