Erik Wissner, MD, F.A.C.C. Asklepios Klinik St. Georg Hamburg, Germany on behalf of the VTACH Study group

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1 Impact of Inducibility of VT during Ablation and Acute Success of Catheter Ablation on Survival Free from VT/VF and ICD Shocks: Lessons from the VTACH Study Erik Wissner, MD, F.A.C.C. Asklepios Klinik St. Georg Hamburg, Germany on behalf of the VTACH Study group

2 Disclosure of Relationships Lecture honoraria - Biosense Webster, Stereotaxis, Biotronik, St. Jude Medical

3 VTACH Study Patients with prior MI and reduced EF 50% 1st episode of stable VT ICD R Catheter ablation ICD only 1 Endpoint: Any recurrence of VT Kuck KH et al, Lancet 2010; 375:31-40

4 VTACH Study Time to Recurrence of VT / VF Ablation group: median 18.6 months [lower quartile 2.4, upper quartile not determinable] Control group: median 5.9 months [IQR ] Survival free from VT/VF at 2 years 47% in the ablation group 29% in the control group hazard ratio 0.61; 95% CI ; p=0.045 Kuck KH et al, Lancet 2010; 375:31-40

5 VTACH Study Survival free from VT/VF at 2 years 47% 29% Kuck KH et al, Lancet 2010; 375:31-40

6 VTACH Subanalysis Ablation Group Assess the impact of Inducibility of VT during ablation and Acute success of catheter ablation 1. on recurrence of VT/VF 2. time to first ICD shock

7 Methods 45 patients underwent catheter ablation mean age 67±8 years 44 male mean EF 35% 11 European centers Procedure: catheter ablation + ICD Median follow-up : 22.7±7.1 months

8 Catheter Ablation 3-D mapping system Carto, Biosense Webster, Inc, Diamond Bar, CA, USA or Ensite, St Jude Medical, Inc., St. Paul, Minn., USA Mapping criteria for ablation in stable VT and the lesion design for substrate modification in case of non-inducible or unstable VT followed standard criteria 1,2 1.Soejima K et al. Circulation 2001;104: Marchlinski FE et al. Circulation 2000; 101:

9 Successful Ablation Patients with inducible VT: Noninducibility of any VT at the end of the procedure Patients without inducible VT: Substrate modification defined as absence of all channels inside the area of interest or linear ablation along infarct scar targeted based on pace mapping

10 Results I: Ablation in VT (Clinical ) VT induced and targeted : 26 patients (group 1) Purely substrate-based ablation : 19 patients (group 2)

11 Results I: Ablation in VT Kaplan-Meier Curves for Freedom from First VT/VF P = Rate free from VT/VF Group 1 Group 2 Number at risk Y: N: Abl. in VT: Yes Abl. in VT: No Time (months)

12 Results I: Ablation in VT Survival free from : Group 1* [n=26] Group 2* [n=19] p-value First VT/VF after 12 months 69.2 % 52.6% First VT/VF after 24 months 53.9 % 40.9% ICD shock after 12 months 92.3% 68.4 % ICD shock after 24 months 87.2% 62.7% Patients with ICD shock at end of FU 3 (11.5%) 8 (42.1%) * Group 1: ablation in VT Group 2: substrate-based ablation This subanalysis adresses only appropriate ICD interventions

13 Results I: Ablation in VT Kaplan-Meier Curves for Survival Free from ICD Shock Rate free from VT/VF with shock therapy % 62.7% P = Group 1 Group 2 Abl. in VT: Yes Abl. in VT: No Number at risk Y: N: Time (months)

14 Results II: Successful Ablation Acute Result of Ablation Result Patients [N=45] Group Successful 27 A Failure/undetermined 18 B

15 Results II: Successful Ablation Kaplan-Meier Curves for Freedom from First VT/VF P = Survival free from VT/VF Success Failure/Undet Number at risk S: F: Time (months)

16 Results II: Successful Ablation Survival free from : Group A* [n=27] Group B* [n=18] p-value First VT/VF after 12 months 70.4 % 49.4% 0.37 First VT/VF after 24 months 51.8 % 42.3% 0.37 Patients with ICD shock at end of FU 5 (18.5%) 6 (33.3%) *Group A: successful ablation *Group B: failure/undetermined ablation This subanalysis adresses only appropriate ICD interventions

17 Limitations Number of patients in subgroups low No blanking period for redo ablations

18 Conclusions In patients with previous myocardial infarction, diminished ejection fraction and stable VT, catheter ablation results in fewer ICD shocks if VT can be induced and targeted during ablation

19 Conclusions Ablation during VT does not translate into longer survival free from VT/VF following ICD implantation Acute success at time of ablation does not result in better outcome