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VANISH: Catheter ablation superior to drugs for treating recurrent ventricular tachycardia

SAN FRANCISCO — Catheter ablation benefited certain patients with MI and an implantable cardioverter defibrillator more than escalating antiarrhythmic drugs, according to results of the VANISH trial presented at the Heart Rhythm Society Scientific Sessions.

Patients with ischemic cardiomyopathy, an ICD and recurrent ventricular tachycardia already taking an antiarrhythmic drug had a lower rate of ventricular tachycardia storm and appropriate ICD shock when treated with catheter ablation vs. escalated medical therapy, researchers reported.

John L. Sapp, MD, from the department of medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada, and colleagues randomly assigned 259 patients to either ablation (n = 132) or escalated therapy (n = 127) and followed them for a mean of 27.9 months. Patients in the escalated therapy group were given amiodarone if they had been previously taking another agent. Mexiletine was added if the patient was already receiving at least 300 mg per day of amiodarone.

The primary endpoint was composite of death, ventricular tachycardia storm — defined as three or more episodes of ventricular tachycardia within 24 hours — or appropriate ICD shock. The results were simultaneously published in The New England Journal of Medicine.

According to the results, 59.9% of the patients in the ablation group met the primary outcome vs. 68.5% in the escalated-therapy group. The rate of primary outcome was lower in ablation group (HR = 0.72; 95% CI, 0.53-0.98). No differences in mortality rate between the two groups were observed (HR = 0.96; 95% CI, 0.6-1.53).

“This was a high-risk population with 50% recurrence of ventricular tachycardia and 25% mortality over 3 years, with most deaths due to HF or non-cardiac causes, which may be why we didn’t see a difference in mortality,” Sapp said during a presentation.

According to Sapp, treatment-related adverse events were more frequent among patients in the escalated-therapy group (51 vs. 22; P = .002) and occurred in more patients (39 vs. 20; P = .003). – by Tracey Romero

References:

Sapp, JL, et al. LBCT 1. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 4-7, 2016; San Francisco.

Sapp JL, et al. N Engl J Med. 2016; doi:10.1056/NEJMoa1513614.

Disclosure: The trial was funded by Biosense Webster and St. Jude Medical. Sapp reports receiving grant support from Johnson & Johnson and St. Jude Medical, receiving personal fees from Medtronic and St. Jude Medical and holding one patent and two pending patents.

 

SAN FRANCISCO — Catheter ablation benefited certain patients with MI and an implantable cardioverter defibrillator more than escalating antiarrhythmic drugs, according to results of the VANISH trial presented at the Heart Rhythm Society Scientific Sessions.

Patients with ischemic cardiomyopathy, an ICD and recurrent ventricular tachycardia already taking an antiarrhythmic drug had a lower rate of ventricular tachycardia storm and appropriate ICD shock when treated with catheter ablation vs. escalated medical therapy, researchers reported.

John L. Sapp, MD, from the department of medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada, and colleagues randomly assigned 259 patients to either ablation (n = 132) or escalated therapy (n = 127) and followed them for a mean of 27.9 months. Patients in the escalated therapy group were given amiodarone if they had been previously taking another agent. Mexiletine was added if the patient was already receiving at least 300 mg per day of amiodarone.

The primary endpoint was composite of death, ventricular tachycardia storm — defined as three or more episodes of ventricular tachycardia within 24 hours — or appropriate ICD shock. The results were simultaneously published in The New England Journal of Medicine.

According to the results, 59.9% of the patients in the ablation group met the primary outcome vs. 68.5% in the escalated-therapy group. The rate of primary outcome was lower in ablation group (HR = 0.72; 95% CI, 0.53-0.98). No differences in mortality rate between the two groups were observed (HR = 0.96; 95% CI, 0.6-1.53).

“This was a high-risk population with 50% recurrence of ventricular tachycardia and 25% mortality over 3 years, with most deaths due to HF or non-cardiac causes, which may be why we didn’t see a difference in mortality,” Sapp said during a presentation.

According to Sapp, treatment-related adverse events were more frequent among patients in the escalated-therapy group (51 vs. 22; P = .002) and occurred in more patients (39 vs. 20; P = .003). – by Tracey Romero

References:

Sapp, JL, et al. LBCT 1. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 4-7, 2016; San Francisco.

Sapp JL, et al. N Engl J Med. 2016; doi:10.1056/NEJMoa1513614.

Disclosure: The trial was funded by Biosense Webster and St. Jude Medical. Sapp reports receiving grant support from Johnson & Johnson and St. Jude Medical, receiving personal fees from Medtronic and St. Jude Medical and holding one patent and two pending patents.

 

    Perspective
    Daniel J. Cantillon

    Daniel J. Cantillon

    VANISH is a really terrific study that looked at ablation as a second-line treatment for patients already on antiarrhythmic drugs. The findings confirmed that ablation should be the second line of therapy if not the first line of therapy for ventricular tachycardia.

    The difference in arrhythmias as well as the fact that there were more adverse events with drugs than with ablation, particularly in patients on amiodarone, were important findings. This can seem counterintuitive from a patient perspective, because they expect ablation to carry a greater risk because it is an invasive procedure. The next step in research is to ask whether ablation should go further and be considered a primary therapy.

    • Daniel J. Cantillon, MD, FACC, FHRS
    • Staff physician, Section of Cardiac Electrophysiology and Pacing Medical Director, Central Monitoring Unit Associate Professor of Medicine Cleveland Clinic

    Disclosures: Cantillon reports no relevant financial disclosures.

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