Original Investigation
Ablation of Stable VTs Versus Substrate Ablation in Ischemic Cardiomyopathy: The VISTA Randomized Multicenter Trial

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Abstract

Background

Catheter ablation reduces ventricular tachycardia (VT) recurrence and implantable cardioverter defibrillator shocks in patients with VT and ischemic cardiomyopathy. The most effective catheter ablation technique is unknown.

Objectives

This study determined rates of VT recurrence in patients undergoing ablation limited to clinical VT along with mappable VTs (“clinical ablation”) versus substrate-based ablation.

Methods

Subjects with ischemic cardiomyopathy and hemodynamically tolerated VT were randomized to clinical ablation (n = 60) versus substrate-based ablation that targeted all “abnormal” electrograms in the scar (n = 58). Primary endpoint was recurrence of VT. Secondary endpoints included periprocedural complications, 12-month mortality, and rehospitalizations.

Results

At 12-month follow-up, 9 (15.5%) and 29 (48.3%) patients had VT recurrence in substrate-based and clinical VT ablation groups, respectively (log-rank p < 0.001). More patients undergoing clinical VT ablation (58%) were on antiarrhythmic drugs after ablation versus substrate-based ablation (12%; p < 0.001). Seven (12%) patients with substrate ablation and 19 (32%) with clinical ablation required rehospitalization (p = 0.014). Overall 12-month mortality was 11.9%; 8.6% in substrate ablation and 15.0% in clinical ablation groups, respectively (log-rank p = 0.21). Combined incidence of rehospitalization and mortality was significantly lower with substrate ablation (p = 0.003). Periprocedural complications were similar in both groups (p = 0.61).

Conclusions

An extensive substrate-based ablation approach is superior to ablation targeting only clinical and stable VTs in patients with ischemic cardiomyopathy presenting with tolerated VT. (Ablation of Clinical Ventricular Tachycardia Versus Addition of Substrate Ablation on the Long Term Success Rate of VT Ablation (VISTA); NCT01045668)

Key Words

amiodarone
catheter ablation
ischemic cardiomyopathy
myocardial infarction
outcomes
ventricular tachycardia

Abbreviations and Acronyms

AADs
antiarrhythmic drugs
HR
hazard ratio
IC
ischemic cardiomyopathy
ICD
implantable cardioverter-defibrillator
LV
left ventricle
LVEF
left ventricular ejection fraction
3D
three-dimensional
VT
ventricular tachycardia

Cited by (0)

Dr. Di Biase is a consultant for Biosense Webster, Boston Scientific, St. Jude Medical, Janssen, and Stereotaxis; has received speaker honoraria/travel from Medtronic, Atricure, EPiEP, and Biotronik; and has received travel/compensation from Pfizer. Dr. Burkhardt is a speaker/consultant for and has received fees from Biosense Webster and Stereotaxis. Dr. Lakkireddy is a consultant to Biosense Webster and St. Jude Medical. Dr. Hongo is a speaker for St. Jude Medical, Japan; and a consultant for Boston Scientific. Dr. Hao is a consultant to Biosense Webster and a speaker for Medtronic. Dr. Natale has received speaker honorariums from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic; and is a consultant for Biosense Webster, St. Jude Medical, and Janssen. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.