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Canadian Journal of Cardiology

Catheter Ablation of Ventricular Arrhythmia in Patients With an Implantable Cardioverter-Defibrillator: A Systematic Review and Meta-analysis

Published:December 12, 2022DOI:https://doi.org/10.1016/j.cjca.2022.12.004

      Abstract

      Background

      Implantable cardioverter-defibrillator (ICD) shocks are associated with higher rates of mortality and reduced quality of life. In this study we aimed to investigate the effectiveness of catheter ablation (CA) of ventricular tachycardia in patients with an ICD.

      Methods

      An electronic literature search was conducted to identify randomized controlled trials that compared CA vs control. The primary outcomes were recurrence of ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) and mortality. Kaplan–Meier curves for these outcomes were digitized to obtain individual patient data, which were pooled in a 1-stage meta-analysis to determine hazard ratios (HRs) and 95% confidence intervals (CIs). Secondary outcomes included cardiac hospitalization, electrical storm, syncope, appropriate ICD therapy, appropriate ICD shocks, and inappropriate shocks. For these, study-level HRs or risk ratios were obtained and pooled in random effects meta-analyses. Subgroup analysis was performed for trials that investigated prophylactic CA (before or during ICD implantation).

      Results

      Data on 9 studies and 1103 patients were retrieved. CA significantly reduced ventricular tachycardia/ventricular fibrillation recurrence compared with control (shared frailty HR, 0.63; 95% CI, 0.49-0.81; P < 0.001) but not mortality (shared frailty HR, 0.84; 95% CI, 0.57-1.23; P = 0.361). CA was associated with significantly lower rates of cardiac hospitalization, electrical storm, appropriate ICD therapies and shocks, but not syncope or inappropriate shocks. Subgroup analysis showed similar results for prophylactic CA except that no significant difference was observed for cardiac hospitalizations.

      Conclusions

      CA is associated with reduced ventricular arrhythmia recurrence, appropriate ICD shocks, and cardiac hospitalization, and might be effective in preventing future morbidity. Future trials are needed to support the continued benefit of these promising results, and to investigate the optimal timing of ablation.

      Résumé

      Contexte

      Les décharges électriques délivrées par un défibrillateur cardioverteur implantable (DCI) sont associées à des taux de mortalité supérieurs et à une qualité de vie amoindrie. Notre étude visait à évaluer l’efficacité de l’ablation par cathéter (AC) de la tachycardie ventriculaire chez les patients porteurs d’un DCI.

      Méthodologie

      Nous avons réalisé une recherche dans les publications électroniques afin de relever les essais contrôlés avec répartition aléatoire comparant l’AC à l’absence d’AC (témoin). Les principaux critères d’évaluation étaient la récurrence de l’arythmie ventriculaire (tachycardie ou fibrillation ventriculaire) et la mortalité. Les courbes de Kaplan–Meier relatives à ces critères ont été numérisées pour obtenir des données individuelles sur les patients, qui ont ensuite été regroupées pour réaliser une méta-analyse simple visant à calculer les rapports des risques instantanés (RRI) et les intervalles de confiance (IC) à 95 %. Les critères d’évaluation secondaires comprenaient l’hospitalisation en raison d’une manifestation cardiaque, la survenue d’une tempête électrique, la survenue d’une syncope, le recours à un DCI approprié, la délivrance d’une décharge appropriée par DCI et la délivrance d’une décharge inappropriée. Les RRI ou les rapports de risques associés à ces critères ont été obtenus pour chaque étude et regroupés dans des méta-analyses à effets aléatoires. Une analyse de sous-groupe comprenant les essais évaluant l’AC prophylactique (avant ou pendant l’implantation d’un DCI) a aussi été réalisée.

      Résultats

      Nous avons extrait les données de 9 études portant sur 1103 patients. L’AC a significativement réduit la récurrence de la tachycardie et de la fibrillation ventriculaires par rapport à l’absence d’AC (RRI pour la fragilité partagée : 0,63; IC à 95 % : 0,49-0,81; p < 0,001), mais pas la mortalité (RRI pour la fragilité partagée : 0,84; IC à 95 % : 0,57-1,23; p = 0,361). L’AC a été associée à des taux significativement plus faibles d’hospitalisation en raison d’une manifestation cardiaque, de survenue d’une tempête électrique, de recours à un DCI approprié et de délivrance d’une décharge appropriée par DCI, mais pas de survenue d’une syncope ou de délivrance d’une décharge inappropriée. Les résultats de l’analyse de sous-groupe portant sur l’AC prophylactique concordaient avec ces observations, à l’exception du fait qu’aucune différence significative n’a été constatée pour ce qui de l’hospitalisation en raison d’une manifestation cardiaque.

      Conclusions

      L’AC est associée à une réduction de la récurrence de l’arythmie ventriculaire, de la délivrance de décharges appropriées par DCI et des hospitalisations en raison d’une manifestation cardiaque, et pourrait se révéler efficace pour prévenir la morbidité future. D’autres essais devraient être réalisés dans le but d’étayer la persistance des bienfaits que ces résultats prometteurs semblent montrer et de déterminer le moment optimal pour effectuer l’ablation.
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      Linked Article

      • Catheter Ablation of Ventricular Tachycardia: Making a Difference, but Not Saving Lives?
        Canadian Journal of Cardiology
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          The development of ventricular tachycardia (VT) in the setting of structural heart disease (SHD) is a harbinger of doom. VT carries with it the obvious risk of sudden arrhythmic death, which is largely mitigated by implantable cardioverter defibrillators (ICDs). Yet these devices do not prevent or reduce VT, and the further effects of VT have become clear in the ICD era. Recurrent ICD shocks are associated with increased subsequent mortality,1 and even recurrent antitachycardia pacing is associated with increased morbidity.
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