9/14/2019 Disclosures Baylis Medical Consultant Honorarium Recipient Biosense Webster Johnson & Johnson Honorarium Recipient CON: VT Ablation Should be First Line Therapy Pfizer Medical Honorarium Recipient Before ICD Implant in Patients Presenting with Bayer Honorarium Recipient Servier Honorarium Recipient Monomorphic VT Peter Leong-Sit, MD MSc FRCPC FHRS Associate Professor of Medicine, Western University London Heart Rhythm Program September 13, 2019 The Bully and the Underdog Point #1: Risk of Sudden Death • Structural heart disease + ventricular Me – just trying to fight for the truth tachycardia = risk of sudden death • Old lesson from AVID, CIDS, and CASH • RCTs of 2* prevention with VT/VF AVID Investigators. NEJM 1997; 337:1576-83. Sensei Dr. William Sauer and the powerful Connolly et al. Circ 2000; 101:1297-302. Cobra Kai Brigham & Women’s EP Team Kuck et al. Circ 2000; 102:748-54. 1
9/14/2019 AVID CIDS & CASH - Patients AVID CIDS & CASH - Meta-analysis Connolly et al. Eur Heart J 2000; 21:2071-8. Connolly et al. Eur Heart J 2000; 21:2071-8. Prognosis with LVEF 35-50% Point #1 • 5 year all-cause mortality Therefore, we have established that – LVEF < 35%: 40-45% patients with structural heart disease – LVEF 35-50%: 20-25% and monomorphic VT, even with an • Hence, despite a better prognosis, a LVEF above 35%, carries a substantial risk population with structural heart disease and of mortality VT still has substantial mortality Connolly et al. Eur Heart J 2000; 21:2071-8. 2
9/14/2019 Point #2: ICD’s unequivocally work! ICDs work in those with MMVT CIDS, AVID, & CASH – Meta-analysis on Mortality MADIT-II: Ischemic CM SCD-HeFT: Ischemic and NICM Moss AJ et al. NEJM 2002; 346:877-83 Bardy GH et al. NEJM 2005; 352:225-37 Connolly et al. Eur Heart J 2000; 21:2071-8. Why not an ICD? Painless Rx Inappropriate Shocks are Low • VT can be terminated the majority of the time painlessly Wathen et al. PainFree II. Circ 2004; 110:2591-6 Sedlacek et al. MADIT-RIT. JCE 2015;26:424-33 3
9/14/2019 Point #2 “They fixed my breaks, I don’t need my seatbelt.” Therefore, we have established that ICDs are effective tools to reduced mortality and can often do so in a painless manner Always wear your seatbelt. (I’ll take the ICD please!) This is a reproducible finding Point #3: We aren`t perfect at VT ablation • VANISH Trial VTACH Trial – N=259 patients with HR 0.47, 0.24-0.88 • N=107 with stable VT p=0.016 ischemic CM and and prior MI MMVT failing drugs • Randomized to ICD – Randomized to drug with VT ablation vs escalation vs ICD alone ablation Kuck KH et al. Lancet 2010;375:31-40 Sapp J et al. NEJM 2016;375:111-21 4
9/14/2019 Amiodarone is tough to beat Network Meta-analysis • IschCM VT – 16 RCTs (11 manuscripts, 3 abstracts) Ablation is better than increasing amiodarone if amiodarone failed BUT, amiodarone first line was just as good as ablation Sapp J et al. NEJM 2016;375:111-21 Leong-Sit et al. HRS 2017. Cautionary Tale: Amiodarone Your VT will be cured! Magic VT Ablation Beans When something seems too good to be true.... Bardy GH et al. NEJM 2005; 352:225-37 5
9/14/2019 In summary… Point #3 1) There’s a established risk of sudden death in patients with VT and structural heart disease 2) ICDs are reliable at reducing sudden death, often VT ablation techniques are imperfect with painless therapies and give rise to variable results. 3) VT ablation is imperfect and techniques and results are variable ACC/AHA/HRS Guidelines Rebuttal 6
9/14/2019 When Shown Results Like This: Secret in EP: We aren’t Perfect at VT ablation (Except for our Me... Except for our Lab...) “Well, their results are poor because we just know how to do this ablation better.” The truth is VT ablation is variable VT Ablation is So Variable... My centre Dr. Roberts UCSF Dr. Leong-Sit UPenn 7
9/14/2019 ICDs are much more standardized Point #4: What about non-ischemic VTs? • Cardiac sarcoid with MMVT ablation • N=5 cohort studies, n=83 patients • Mean/median follow-up: 20-27 months • At least 1 VT recurrence in 45/83 (54%) Big Mac in New York Big Mac in Los Angeles Papageorgiou et al. Europace 2018;20:682-91. ARVC VT Ablation Point #4 • N=110 with ARVC and >3 VT episodes VT ablation is likely even less robust in the • N=75 underwent ablation non-ischemic population such as cardiac sarcoid or arrhythmogenic • At 3 years, ablation 35% vs drugs 28% VT-free cardiomyopathy. • Overall, 56% were VT-free after last ablation procedure Mahida S et al. Heart Rhythm 2019;16:536-43. 8
9/14/2019 In summary… We must therefore conclude: 1) There’s a established risk of sudden death in While VT ablation, especially in expert centres, patients with VT and structural heart disease may have a good role in VT reduction... 2) ICDs are reliable at reducing sudden death, often with painless therapies VT Ablation Should NOT be First Line 3) VT ablation is imperfect and techniques and results Therapy Before ICD Implant in Patients are variable 4) We’re probably even worse at non -ischemic VT Presenting with Monomorphic VT ablation Thank You Dr. Sauer Dr. Leong-Sit 9
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