Prophylactic ablation

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1 Ventricular tachycardia in ischaemic heart disease. Update on electrical therapy 29 august 2010 Prophylactic ablation Pasquale Notarstefano Cardiovacular Department S. Donato Hospital, Arezzo (IT)

2 Prophylactic ablation Catheter ablation: Aimed to reduce the risk of VT/VF and appropriate ICD therapy In high risk patients requiring an ICD Before any ICD intervention

3 Rationale for prophylactic ablation Recurrent ICD shocks are associated to Reduced quality of life (Mark DB et al, NEJM 2008;359: ) Increased mortality rate (Poole JE et al, NEJM 2008;359: ) 5% rate of ICD unresponsive SCD (Mitchell LB et al, JACC 2002:39; )

4 Rationale for prophylactic ablation Ablation has shown to be able to significantly reduce episodes of recurrent VT Advances in technology allow ablation of unstable and multiple VT Life time intake of antiarrhythmic drugs is difficult for side effects (Calkins H et al, JACC 2000;35: ) (Multicenter thermocool VT ablation trial, Stevenson et al, Circulation 2008;118: ) (Euro-VT Study, Tanner et al, JCE 2010;21:47-53)

5 Rationale for prophylactic ablation OPTIC STUDY, 412 patients % of patient receiving shocks: βblockers 38.5% Sotalol 24.3% Amiodarone+βblockers 10.3% Rate of drug discontinuation: βblockers 5.3% Sotalol 23.5% Amiodarone+βblockers 18.2% Connolly et al, JAMA ; 295(2):165-71

6

7 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias The task force members felt that ablation should generally be considered relatively early, before multiple recurrences of VT and repeated courses of drug therapy. How early? What about patients with indication to ICD implantation for II prevention who have not received ICD therapy (yet)?

8 SMASH VT STUDY

9 AIM OF SMASH VT To assess the efficacy of prophylactic VT ablation in preventing ICD therapy in patients with: Previous myocardial infarction Undergoing ICD implantation for life-threatening arrhythmic events. Reddy et al, NEJM 2007;357:

10 SMASH VT 128 patients in 3 centres: Planned or recent ICD for Ventricular fibrillation Unstable ventricular tachycardia Syncope with inducible VT during EP Ablation group Control group Substrate ablation in sinus rhythm No further therapy Exclusion criteria: Class I and III antiarrhythmic drugs Incessant or multiple episodes of VT Mean follow up 23 months Reddy et al, NEJM 2007;357:

11 SMASH VT Endpoints I ) Survival free from any appropriate ICD therapy II )Freedom from -any appropriate ICD shock -death -ICD storm Reddy et al, NEJM 2007;357:

12 SMASH VT Primary Endpoint ABLATION CONTROL HR (95% CI) ICD events 12% 33% 0.35 ( ) Reddy et al, NEJM 2007;357:

13 SMASH VT RESULTS (mean follow up 23 months) Reddy et al, NEJM 2007;357:

14 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias About SMASH VT Prophylactic VT ablation in patients with ICDs implanted for primary or secondary prevention is investigational, and further trials are needed to assess this approach.

15 VTACH STUDY Kuck et al, Lancet 2010;375:31-40

16 AIM OF VTACH STUDY To assess the efficacy of prophylactic VT ablation in patients with: Previous MI, LVEF <50% Before ICD implantation for first episode of stable VT (SBP>90mmHg, no syncope or cardiac arrest) Kuck et al, Lancet 2010;375:31-40

17 VTACH STUDY 107 patients in 16 centres Documented stable VT, previous MI, EF <50% Ablation group EP study Control group Catheter ablation ICD ICD Follow up at least 1 year, mean 22 months Kuck et al, Lancet 2010;375:31-40

18 VTACH STUDY PRIMARY END POINT Time from ICD implantation to recurrence of any sustained VT or VF SECONDARY END POINTS Survival free from Death Syncope Hospital admission for cardiac reasons VT storm Number of appropriate ICD interventions Kuck et al, Lancet 2010;375:31-40

19 VTACH STUDY Primary Endpoint ABLATION CONTROL TIME TO FIRST VT OR VF (MONTHS) Kuck et al, Lancet 2010;375:31-40

20 VTACH STUDY Primary Endpoint Kuck et al, Lancet 2010;375:31-40

21 VTACH STUDY RESULTS

22 Safety of prophylactic ablation No ablation related death in both studies VTACH n 2 complications (3,8%) Transient ischemic ST-elevation Transient cerebral ischemic event Smash VT n 3 complications (4,7%) Pericardial effusion Exacerbation of HF Deep venous thrombosis

23 Unanswered questions Which is the best timing for catheter ablation? Which subgroups of patients are more likely to benefit? What about: Catheter ablation vs antiarrhythmic drugs Quality of life Costs Epicardial ablation

24 Conclusions Prophylactic ablation prolongs the time to first recurrence of ventricular arrhythmias, reduces VT recurrences and ICD interventions The rate of procedure-related complications is low

25 Conclusions Prophylactic ablation should be strongly considered before implantation of a cardioverter defibrillator KH Kuck et al Lancet 2010;375:40 Evidence of a positive effect on survival, hospital admission or quality of life is needed before this strategy can be recommended for routine use WG Stevenson,U Tedrow,Lancet 2010;375:6

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