VTACH: Ablation beneficial prior to ICD insertion

Patients who suffer from ventricular tachycardia following myocardial infarction are at a high risk of sudden death.  This risk can be reduced by implantable cardioverter defibrillator (ICD) insertion, however patients with an ICD who receive ICD shocks have a decreased quality of life and increased mortality compared with patients who do not receive shocks, even if the shocks are inappropriate.
The Ventricular Tachcardia Ablation in Coronary Heart Disease (VTACH) study was a prospective, randomised controlled trial designed to investigate whether catheter ablation of ventricular tachycardia prior to ICD insertion could be beneficial.  110 patients with stable ventricular tachycardia, prior myocardial infarction, and a left ventricular ejection fraction of less than 50% were randomised to either catheter ablation and an ICD (n=54) or an ICD alone (n=56).  Patients were followed up for at least one year; the primary endpoint was the time to first recurrence of either ventricular tachycardia or ventricular fibrillation.

The mean follow-up period was 22.5 months, and time to recurrence of arrhythmia was longer in the ablation group (median 18.6 months) than in the control group (5.9 months).  At 2 years, 47% of patients who had received ablation were alive and had not suffered a recurrent ventricular arrhythmia, compared to only 29% in the control group (p=0.045).  Nine patients died during the study; five in the ablation group and four in the control group.
Conclusions:
Prophylactic ablation of a ventricular arrhythmia prior to ICD implantation prolonged the time recurrence of ventricular tachycardia in patients with stable VT, previous infarction, and a low ejection fraction.  Although larger numbers and longer follow-up are needed to prove a definite clinical benefit, this technique should be considered before implantation of an ICD in such patients.
Kuck KH, Schaumann A, Willems S, et al. Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): A multicenter randomized controlled trial. Lancet 2010; 375: 31-40.
Stevenson WG, Tedrow U. Preventing ventricular tachycardia with catheter ablation. Lancet 2010; 375: 4-6.

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