Patients treated with catheter ablation for ventricular tachycardia after an ICD shock have lower long-term rates of death and heart failure hospitalization than do patients treated with medical management only
BACKGROUND Ventricular arrhythmias in patients with implantable cardioverter-deﬁbrillators (ICDs) adversely affect outcomes. Antiar- rhythmic approaches to ventricular tachycardia (VT) have variable efﬁcacy and may increase risk of ventricular arrhythmias, worsening cardiomyopathy, and death. Comparatively, VT ablation is an alternative approach that may favorably affect outcomes.
OBJECTIVE To further explore the effect on long-term outcomes after catheter ablation of VT, we compared patients with history of ICD shocks who did not undergo ablation, patients with a history of ICD shocks that underwent ablation, and patients with ICDs who had no history of ICD shocks.
METHODS A total of 102 consecutive patients with structural heart disease who underwent VT ablation for recurrent ICD shocks were compared with 2088 patients with ICDs and no history of appropriate shocks and 817 patients with ICDs and a history of appropriate shocks for VT or ventricular ﬁbrillation. Outcomes considered were mortality, heart failure hospitalization, atrial ﬁbrillation, and stroke/transient ischemic attack.
RESULTS The mean age of 3007 patients was 65.4 ± 13.9 years. Over long-term follow-up, 866 (28.8%) died, 681 (22.7%) had a heart failure admission, 706 (23.5%) developed new-onset atrial ﬁbrillation, and 224 (7.5%) had a stroke. The multivariate-adjusted risks of deaths and heart failure hospitalizations were higher in Dr Bunch is a consultant for St Jude Medical and Biosense Webster as well as an advisory board member with Boston Scientiﬁc. Dr Weiss is a consultant for Merit Medical, Stereotaxis, and Biosense Webster. Dr Crandall is a consultant and speaker for Merit Medical, St Jude Medical, and Boston Scientiﬁc. Dr Osborn is a consultant and speaker for Medtronic, St Jude Medical, Boston Scientiﬁc, and Cook. Dr Fischer, Dr Brunner, and Dr Mahapatra are employees of St Jude Medical. Address reprint requests and correspondence: Dr T. Jared Bunch, Intermountain Heart Rhythm Specialists, Intermountain Medical Center, Eccles Outpatient Care Center, 5169 Cottonwood St, Suite 510, Murray, UT 84107. E-mail address: [email protected] patients with history of ICD shocks who were treated medically than in patients with ICDs and no history of shock (hazard ratio [HR] 1.45; P o .0001 vs HR 2.00; P o .0001, respectively). The multivariate-adjusted risks were attenuated after VT ablation with death and heart failure hospitalization rates similar to those of patients with no shock (HR 0.89; P ¼ .58 vs HR 1.38; P ¼ .09,respectively). A similar nonsigniﬁcant trend was seen with stroke/ transient ischemic attack.
CONCLUSIONS Patients treated with VT ablation after an ICD shock have a signiﬁcantly lower risk of death and heart failure hospitalization than did patients managed medically only. The adverse event rates after VT ablation were similar to those of patients with ICDs but without VT.
KEYWORDS Ventricular tachycardia; Catheter ablation; Heart failure; Mortality; Atrial ﬁbrillation
ABBREVIATIONS AF ¼ atrial ﬁbrillation; HR ¼ hazard ratio; ICD ¼ implantable cardioverter-deﬁbrillator; ICD-9 ¼ International Classiﬁcation of Diseases, Ninth Revision; IQR ¼ interquartile range; TIA ¼ transient ischemic attack; VF ¼ ventricular ﬁbrillation; VT ¼ ventricular tachycardia
(Heart Rhythm 2014;11:533–540) I 2014 Heart Rhythm Society. All rights reserved.