Catheter Ablation of Recurrent Ventricular Tachycardia Should Be Done Before Antiarrhythmic Therapy with Amiodarone is Tried CONTRA Erik Wissner, MD, F.A.C.C. Director - Magnetic Navigation Laboratory Asklepios Klinik St. Georg Hamburg, Germany
Role of ICD in VT Treatment Challenges ICD is the mainstay of therapy to prevent sudden cardiac death, leading to reduction of total mortality BUT: ICDs do not prevent ocurrence of VT SCD rate 5% in ICD patients ICD shocks are associated with increased mortality Recurrent ICD interventions reduce QoL
Treatment Options Prevention of ICD shocks (interventions) Antiarrhythmic drugs Catheter ablation
. Catheter Ablation of VT EHRA/HRS Expert Consensus Document Aliot et al. Heart Rhythm 2009;6(6):886 933
Amiodarone Suppresses ventricular arrhythmia Prolongs cycle length of VT - preventing syncope - allowing for ATP Suppresses atrial tachycardias (AF) present in nearly 30% of patients
Treatment Options to Reduce ICD Shocks Antiarrhythmic drugs OPTIC Trial p < 0.001 p < 0.02 Connolly SJ et al. JAMA 2006;295:165 71
Catheter Ablation of Ventricular Arrhythmias in ICD Patients Kuck KH Lancet 2010;375:31-40
Continuation of Antiarrhythmic Drugs Supplemental Table 1. Antiarrhythmic Drug Therapy Total Success Failure p % % % Antiarrhythmic drugs at Ablation n = 231 Class I AAD % 31 30 32 Class lli AAD % 16 15 16.927 Amiodarone % 52 54 50.532 AAD after Ablation n = 217 Combination 22 23 21.817 Any AAD % 76 71 83 0.031 Class I Drug % 18 14 22 0.132 Class III Drug % 18 14 23 Amiodarone % 51 50 51 1.0 Drug Combination % 15 12 18.258 AAD last F/U n = 214 Any AAD % 72 65 82 0.003 Class I Drug % 18 10 28 0.002 Class III Drug % 17 12 24 Amiodarone % 47 44 51.46 Drug Combination % 14 7 24 <.001 warfarin after ablation % pts 71 72 69 0.59 Stevenson et al. Circulation 2008;118(25):2773 2782
Complications of VT Ablation Stevenson et al. Circulation Supplemental 2008;118(25):2773 2782 Table 2. Procedural Complications N % patients Fatal Complications 7 3.0 Uncontrollable VT 6 2.6 Tamponade/MI 1 0.4 Non-Fatal Complications 27 complications in 24 patients Calkins et al. JACC 2000;35(7):1905 10.0 Heart Failure 6 2.6 COPD exacerbation 1 0.4 Femoral Bleeding 7 3.0 Femoral Pseudoaneurysm 4 1.7 Hematuria 1 0.4 HIT sepsis 1 0.4 Increase in mitral regurgitation 1 0.4 Incessant VT 1* 0.4 Pericarditis 1 0.4 Atrial ICD lead malfunction 1 0.4
VTACH 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
VTACH : Secondary Endpoints Survival free from Death Syncope Hospitalization for cardiac reason VT storm Number of appropriate ICD interventions Quality of life Kuck KH et al, Lancet 2010; 375:31-40
VTACH : Results Kaplan-Meier Analysis: Time from ICD implant to first VT/VF 1.0 Survival free from VT/VF [%] 0.9 P = 0.045 Control Ablation Survival free from VT/VF 0.8 0.7 0.6 0.5 0.4 0.3 0.2 Ablation Control 12M 40,4 58,7 24 M 28,8 46,4 p= 0,045 (Log-Rank) 0.1 0.0 0 6 12 18 24 30 36 42 48 Time (months) Intention to treat analysis; category 1 VTs only Kuck KH et al, Lancet 2010; 375:31-40
Survival free from VT/VT Survival free of VT/VT VTACH : Results KM-Analysis: Time from ICD implant to first VT/VF in patients with LVEF 30% (A) LVEF > 30% (B) A 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 P = 0.758 Ablation Control B 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 P = 0.016 Ablation Control 0 6 12 18 24 30 36 42 48 Time (months) 0 6 12 18 24 30 36 42 48 Time (months) Censored (Ablation) Censored (Control) Censored (Ablation) Censored (Control) Intention to treat analysis; category 1 VTs only Kuck KH et al, Lancet 2010; 375:31-40
VTACH Results: Secondary EP No difference between study groups were found for the secondary endpoints Death Syncope VT storm Kuck KH et al, Lancet 2010; 375:31-40
Cost over 5-year Period Calkins et al, Circulation 2000;101(3):280
Catheter Ablation in NICM No prospective randomized trial in NICM Lower rate of ICD shocks in NICM (SCD-HeFT 5.1% per year) Moderate longterm success rate in NICM, thus Amiodarone firstline therapy More frequent need for epicardial ablation with inherent risks
CEASE VT Study Design Patients > 18 and < 85 years old with CAD, MI and a prophylactic ICD with at least one appropriate shock R Ablation Arm (160 pts) 30 day Treatment Period: Perform Ablation Amiodarone Arm (160 pts) 30 day Treatment Period: Titrate Amiodarone Dr. C. Morrilo Dr. A. Natale Dr. D. Callans Follow-up Period: ICD clinic visits at 1 month, 3 months and every 3 months thereafter + when suspect ICD therapy has occurred Duration up to 48 months
Unresolved Issues No uniform approach to catheter ablation Does prevention of ICD shocks using catheter ablation reduce mortality? When is the best time to tell your patient to proceed with catheter ablation? 0, 2 or more shocks Does Amiodarone have a role in patients with hemodynamically stable VT and EF > 30%
Summary Amiodarone necessary in many patients before and after catheter ablation Effect of catheter ablation in part due to concomitant Amiodarone treatment Prospective randomized trial needed (CEASE VT) Experienced center necessary Tailored approach (EF > 30%, ARVD, hemodynamically stable VT patients, etc.)
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BERLIN Study ICD/CRT-D Home Monitoring R Prophylactic catheter ablation 2 shocks catheter ablation 5 shocks catheter ablation Combined 1 Endpoint: mortality, VT/VF, ICD shocks, rehosp. 2 Endpoint: QOL, ATP interventions
VTACH 2 1st episode of stable VT in CAD EF 30% R Catheter ablation ICD only 1 Endpoint: Any recurrence of VT, death, rehospitalisation for cardiac reasons
Catheter ablation of VT late after MI Unsolved issues When to perform VT ablation in those patients with ICD implantation? - amiodarone versus CA after 1st event (CEASE trial) - How many shock to perform ablation (Berlin trial by Kuck) Do all patients need ICD implantation? - such as pts with stable VT and LVEF > 35 or 40% (VTachy II by Kuck)
VTACH - ICD Interventions Kuck KH Lancet 2010;375:31-40
SMASH-VT ICD Interventions Reddy et al. NEJM 2007;357(26):2657 2665
Antiarrhythmic Drugs Prevention of ICD Shocks (Interventions) Antiarrhythmic drugs associated with side effects discontinuation of amiodarone in 18.2% and of sotalol in 23.5% of patients after one year in the OPTIC trial increases defibrillation threshold often ineffective Connolly SJ et al. JAMA 2006;295:165 71
VT Ablation using CARTO Multicenter Thermocool VT ablation trial 231 pts with recurrent VT LVEF 25% Amiodarone use: 70% ICD in 94% Median of inducible VT: 3 (2-5) Longest CL 440 ms: (370-526 ms) Shortest CL 320 ms: (272-380 ms) Mean of mappable CL: 428 (373-476 ms) Stevenson et al. Circulation 2008;118(25):2773 2782
Situations when Amiodaron is not sufficient Slow incessant VT Electrical storm