VANISH2: Catheter Ablation Viable First-Line Option for Ventricular Tachycardia

John Sapp, MD

Credit: American Heart Association

Catheter ablation could be a better first-line option than anti-arrhythmic drug therapy for patients with previous myocardial infarction experiencing ventricular tachycardia (VT), according to late-breaking science presented at the American Heart Association (AHA) Scientific Sessions 2024.¹

The international Ventricular Tachycardia Antiarrhythmics or Ablation in Structural Health Disease (VANISH2) trial evaluated the effect of first-line catheter ablation versus drug therapy in a population of more than 400 patients with recurrent VT for a more than 4 year period.

“We have previously shown that when a medication is not preventing episodes of VT, ablation has led to better outcomes than increasing the medications,” John Sapp, MD, a professor of medicine and assistant dean of clinical research at Dalhousie University, Queen Elizabeth II Health Sciences Centre, said in a statement.² “Now we know that ablation is a reasonable option for first-line treatment instead of starting with antiarrhythmic medication therapy.”

Myocardial infarction can lead to scar tissue in the heart muscle and block the heart’s ability to function properly, putting patients at risk of dangerous arrhythmia, including VT.³ Anti-arrhythmic medications are used to prevent VT episodes but are linked to notable long-term risks, including worsening of the arrhythmia or damage to other organs.

Catheter ablation is a common treatment option when anti-arrhythmic drugs cannot suppress VT, although it is unknown if it is more effective as a first-line therapy.¹ The VANISH2 trial randomly assigned 416 patients from 22 centers in a 1:1 ratio to receive anti-arrhythmic drug therapy or catheter ablation. All patients had an implantable cardioverter defibrillator (ICD).

Catheter ablation was performed within 14 days after randomization and sotalol or amiodarone was administered as anti-arrhythmic drug therapy. This population was followed for ≥2 years after ablation or while taking the assigned medication (median, 4.3 years). Investigators collected data on death, appropriate ICD shocks, ≥3 VT events within 24 hours, and sustained VT treated urgently in a hospital.

Overall, a primary endpoint event was identified in 103 of 203 patients (50.7%) assigned to catheter ablation and in 129 of 213 (60.6%) on drug therapy (hazard ratio [HR], 0.75; 95% CI, 0.58–0.97; P = .03). This result showed individuals who received ablation were 25% less likely to die or experience VT requiring ICD shock.

Adverse events in the safety data occurred within 30 days after catheter ablation in 2 patients (1.0%) and non-fatal adverse events in 23 patients (11.3%). For those assigned to drug therapy, adverse events attributed to anti-arrhythmic drugs included death from pulmonary toxic effects in 1 patient (0.5%) and nonfatal adverse events in 46 patients (21.6%).

“For people who have survived a heart attack and developed VT, our findings show that performing a catheter ablation to directly treat the heart’s abnormal scar tissue causing the arrhythmia, rather than prescribing heart rhythm medications that can affect other organs as well as the heart, provides better overall outcomes,” Sapp added. “These results may change how heart attack survivors with VT are treated.”

Although the study did not confirm ablation outperformed medication in reducing each adverse outcome, the overall differences favored ablation to reduce VT episodes. However, Sapp indicated these data could not be generalized to patients with heart muscle scarring from diseases other than a blocked coronary artery.

“We also note that, despite these treatments, the rate of VT episodes remained relatively high,” Sapp said. “We still need more research and innovation to develop better treatments for these patients.”

References

1. _{Sapp JL, Tang ASL, Stevenson WG, et al. Catheter Ablation or Antiarrhythmic Drugs for Ventricular Tachycardia. The New England Journal of Medicine. Published November 16, 2024. Accessed November 16, 2024.}
2. _{Ablation may be better than medication for those with dangerous heartbeat after heart attack. American Heart Association. November 16, 2024. Accessed November 16, 2024. https://newsroom.heart.org/news/ablation-may-be-better-than-medication-for-those-with-dangerous-heartbeat-after-heart-attack?preview=6f7e&preview_mode=True.}
3. _{Bhar-Amato J, Davies W, Agarwal S. Ventricular Arrhythmia after Acute Myocardial Infarction: 'The Perfect Storm'. Arrhythm Electrophysiol Rev. 2017 Aug;6(3):134-139. doi: 10.15420/aer.2017.24.1. PMID: 29018522; PMCID: PMC5610731.}