Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia

• Published in: Journal of the American College of Cardiology Vol. 79; no. 15; pp. 1441 - 1453
• Main Authors: Arenal, Ángel, Ávila, Pablo, Jiménez-Candil, Javier, Tercedor, Luis, Calvo, David, Arribas, Fernando, Fernández-Portales, Javier, Merino, José Luis, Hernández-Madrid, Antonio, Fernández-Avilés, Francisco J., Berruezo, Antonio
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 19.04.2022
• Subjects: Aged; Amiodarone - therapeutic use; Anti-Arrhythmia Agents - therapeutic use; antiarrhythmic drugs; Cardiomyopathies - etiology; Catheter Ablation - adverse effects; Defibrillators, Implantable; Female; Heart Failure - drug therapy; Humans; Male; Myocardial Ischemia - etiology; Prospective Studies; substrate ablation; Tachycardia, Ventricular - drug therapy; Tachycardia, Ventricular - surgery; Treatment Outcome; ventricular tachycardia; antiarrhythmic drugs; substrate ablation; ICD; ventricular tachycardia; AAD; VT
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2022.01.050

In patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD), catheter ablation and antiarrhythmic drugs (AADs) reduce ICD shocks, but the most effective approach remains uncertain. This trial compares the efficacy and safety of catheter ablation vs AAD as first-line therapy in ICD patients with symptomatic ventricular tachycardias (VTs). The SURVIVE-VT (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia) is a prospective, multicenter, randomized trial including patients with ischemic cardiomyopathy and appropriated ICD shock. Patients were 1:1 randomized to complete endocardial substrate-based catheter ablation or antiarrhythmic therapy (amiodarone + beta-blockers, amiodarone alone, or sotalol ± beta-blockers). The primary outcome was a composite of cardiovascular death, appropriate ICD shock, unplanned hospitalization for worsening heart failure, or severe treatment-related complications. In this trial, 144 patients (median age, 70 years; 96% male) were randomized to catheter ablation (71 patients) or AAD (73 patients). After 24 months, the primary outcome occurred in 28.2% of patients in the ablation group and 46.6% of those in the AAD group (hazard ratio [HR]: 0.52; 95% CI: 0.30-0.90; P = 0.021). This difference was driven by a significant reduction in severe treatment-related complications (9.9% vs 28.8%, HR: 0.30; 95% CI: 0.13-0.71; P = 0.006). Eight patients were hospitalized for heart failure in the ablation group and 13 in the AAD group (HR: 0.56; 95% CI: 0.23-1.35; P = 0.198). There was no difference in cardiac mortality (HR: 0.93; 95% CI: 0.19-4.61; P = 0.929). In ICD patients with ischemic cardiomyopathy and symptomatic VT, catheter ablation reduced the composite endpoint of cardiovascular death, appropriate ICD shock, hospitalization due to heart failure, or severe treatment-related complications compared to AAD. (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia [SURVIVE-VT]: NCT03734562) [Display omitted]