Ventricular tachycardia ablation in structural heart disease: Impact of ablation strategy and non-inducibility as an end-point on long term outcome

Berndt, Alexander; Sawhney, Vinit; Providência, Rui; Honarbakhsh, Shohreh; Ullah, Waqas; Dhinoja, Mehul; Schilling, Richard J.; Babu, Girish; Chow, Anthony; Lambiase, Pier D.; Rajappan, Kim; Kalla, Manish; Cassar, Mark Philip; Hall, Mark; Temple, Ian P.; Bartoletti, Stefano; Panikker, Sandeep; Kontogeorgis, Andrew; Wong, Tom; Hunter, Ross J.

doi:10.1016/j.ijcard.2018.08.099

Cited by 13 publications

(14 citation statements)

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“…Assumptions in the model including monthly mortality and readmission rates were calculated as a weighted average, accounting for the different RCT sample sizes. The mortality rate of 46% for the hypothetical cohort at 5 years is comparable with large international registry data16 and follow-up data from our own institution 17…”

Section: Methodssupporting

confidence: 73%

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Cost-effectiveness of ablation of ventricular tachycardia in ischaemic cardiomyopathy: limitations in the trial evidence base

et al. 2020

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ObjectiveCatheter ablation is an important treatment for ventricular tachycardia (VT) that reduces the frequency of episodes of VT. We sought to evaluate the cost-effectiveness of catheter ablation versus antiarrhythmic drug (AAD) therapy.MethodsA decision-analytic Markov model was used to calculate the costs and health outcomes of catheter ablation or AAD treatment of VT for a hypothetical cohort of patients with ischaemic cardiomyopathy and an implantable cardioverter-defibrillator. The health states and input parameters of the model were informed by patient-reported health-related quality of life (HRQL) data using randomised clinical trial (RCT)-level evidence wherever possible. Costs were calculated from a 2018 UK perspective.ResultsCatheter ablation versus AAD therapy had an incremental cost-effectiveness ratio (ICER) of £144 150 (€161 448) per quality-adjusted life-year gained, over a 5-year time horizon. This ICER was driven by small differences in patient-reported HRQL between AAD therapy and catheter ablation. However, only three of six RCTs had measured patient-reported HRQL, and when this was done, it was assessed infrequently. Using probabilistic sensitivity analyses, the likelihood of catheter ablation being cost-effective was only 11%, assuming a willingness-to-pay threshold of £30 000 used by the UK’s National Institute for Health and Care Excellence.ConclusionCatheter ablation of VT is unlikely to be cost-effective compared with AAD therapy based on the current randomised trial evidence. However, better designed studies incorporating detailed and more frequent quality of life assessments are needed to provide more robust and informed cost-effectiveness analyses.

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Section: Methodssupporting

confidence: 73%

“…Beyond the RCT follow-up period, reference to large VT ablation registries with long-term follow-up, as well as cohort data from our own institution was used to guide parameter changes 16 17. These additional assumptions had the smallest effect on the base-case analysis due to its shorter time horizon.…”

Section: Discussionmentioning

confidence: 99%

Cost-effectiveness of ablation of ventricular tachycardia in ischaemic cardiomyopathy: limitations in the trial evidence base

et al. 2020

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“…During the last years substrate mapping and ablation without baseline VT induction or activation mapping has proved to be an effective and safe strategy. [9][10][11][12][13] The rationale for this new approach is that complete elimination of the abnormal substrate/ signals is associated with better acute success in terms of noninducibility of any VT (either clinical or not) at the end of the procedure when compared with ablation of the clinical VT only, and has clearly been related with a significant reduction of VT recurrences during follow-up. On the other hand, concerns regarding the development of hemodynamic decompensation during or after VT ablation procedures have also favored the avoidance of baseline VT induction and activation mapping.…”

Section: Utility Of Baseline Inducibility and Activation Mapping During Vt Ablationmentioning

confidence: 99%

“…17,18 Current existing literature in this regard is controversial. [11][12][13] Two previous meta-analyses have evaluated the influence of VT Group 2 patients with acute success at the end of the procedure (determined by non inducibility with PVS) had significantly higher VT recurrence free survival when compared with group 3 patients with acute success (85.4% vs. 63.6%, Log-rank p = .005) (Supplementary data).…”

Section: Utility Of Baseline Inducibility and Activation Mapping During Vt Ablationmentioning

confidence: 99%

“…However, stand-alone substrate ablation has also been advocated as a first ablation strategy even in the absence of these previous conditions thus obviating the evaluation of baseline VT inducibility and the potential utility of VT activation mapping. [9][10][11][12][13] We sought to evaluate the role of baseline VT inducibility and the influence of activation mapping on outcomes in patients with SHD undergoing VT ablation.…”

Section: Introductionmentioning

confidence: 99%

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Influence of baseline inducibility and activation mapping on ablation outcomes in patients with structural heart disease and ventricular tachycardia

Cano

Pérez-Roselló

Ayala

et al. 2021

Cardiovasc electrophysiol

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Introduction: Stand-alone substrate ablation has become a standard ventricular tachycardia (VT) ablation strategy. We sought to evaluate the influence of baseline VT inducibility and activation mapping on ablation outcomes in patients with structural heart disease (SHD) undergoing VT ablation.Methods: Single center, observational and retrospective study including consecutive patients with SHD and documented VT undergoing ablation. Baseline VT induction was attempted before ablation in all patients and VT activation mapping performed when possible. Ablation was guided by activation mapping for mappable VTs plus substrate ablation for all patients. Ablation outcomes and complications were evaluated.Results: One hundred and sixty patients were included and were classified in three groups according to baseline VT inducibility:group 1 (non inducible, n = 18), group 2 (1 VT morphology induced, n = 53), and group 3 (>1 VT morphology induced, n = 89).VT activation mapping was possible in 35%. After a median follow-up of 38.5 months, baseline inducibility of greater than 1 VT morphology was associated with a significant incidence of VT recurrence (42% for group 3 vs. 15.1% for group 2% and 5.6% for group 1, Log-rank p < .0001) and activation mapping with a lower rate of VT recurrence (24% vs. 36.3%, Log-rank p = .035). Baseline inducibility of greater than 1 VT morphology (hazards ratio [HR]: 12.05, 95% confidence interval [CI]:1.60-90.79, p = .016) was an independent predictor of VT recurrence while left ventricular ejection fraction less than 30% (HR: 1.93, 95% CI: 1.13-3.25, p = .014) and advanced heart failure (HR: 4.69, 95% CI: 2.75-8.01, p < .0001) were predictors of mortality or heart transplantation. Complications occurred in 11.2% (5.6% hemodynamic decompensation). Conclusion:Baseline VT inducibility and activation mapping may add significant prognostic information during VT ablation procedures.

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Assessment and Management of Cardiac Rhythm Disturbances (Arrhythmias)

Shepherd¹,

Tagney²,

Kucia³

2022

Cardiac Care

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Ventricular tachycardia ablation in structural heart disease: Impact of ablation strategy and non-inducibility as an end-point on long term outcome

Abstract: CA eliminates VT in a large proportion of patients long term. Ablation strategy did not impact outcome and hence substrate ablation is a reasonable initial strategy. Non-inducibility of VA predicted survival free from VA and may be worth pursuing as a procedural end-point.

Cited by 13 publications

References 40 publications

Cost-effectiveness of ablation of ventricular tachycardia in ischaemic cardiomyopathy: limitations in the trial evidence base

Cost-effectiveness of ablation of ventricular tachycardia in ischaemic cardiomyopathy: limitations in the trial evidence base

Influence of baseline inducibility and activation mapping on ablation outcomes in patients with structural heart disease and ventricular tachycardia

Assessment and Management of Cardiac Rhythm Disturbances (Arrhythmias)

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