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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Article info
Publication history
Published online: December 12, 2022
Accepted:
December 1,
2022
Received:
September 25,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
See editorial by Bennett and Deyell, pages xxx-xxx of this issue.
See page 11 for disclosure information.
Identification
Copyright
© 2022 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Catheter Ablation of Ventricular Tachycardia: Making a Difference, but Not Saving Lives?Canadian Journal of Cardiology
- PreviewThe 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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