Catheter ablation enough in Post-MI patients with more than 35% LVEF and who tolerated ventricular tachycardias: Study

A new study published in the JACC: Clinical Electrophysiology journal showed that when acute procedural success is attained in a subset of patients with ventricular tachycardia (VT) and a left ventricular ejection fraction (LVEF) higher than 35% following myocardial infarction, catheter ablation alone could be enough.

Post–myocardial infarction (MI) individuals with ventricular tachycardia are regarded at risk for VT recurrence and sudden cardiac death (SCD). For more than 20 years, implanted cardioverter-defibrillators (ICDs) have been advised for the prevention of SCD in patients with hemodynamically tolerated sustained monomorphic ventricular tachycardia (SMVT), irrespective of the left ventricular ejection fraction.

According to recent guidelines, catheter ablation should be explored as an alternative to an implanted cardioverter-defibrillator (ICD) in some individuals. This study was to examine the results of patients who were referred for VT ablation based on acute ablation outcome, left ventricular ejection fraction, and VT tolerance.

Post-MI patients without a history of ICD who had VT ablation at a single facility between 2009 and 2022 were included in this research. Catheter ablation was recommended as first-line treatment for patients with tolerable VT and an LVEF greater than 35%. All patients were given the option of ICD implantation, however the choice was made jointly based on the patient's clinical presentation, LVEF, and ablation results.

VT ablation was performed on 86 patients (mean age 69 ± 9 years, 84% male, mean LVEF 41 ± 9%). 51 of the 66 patients with LVEF >35% have tolerated VT and 37 (73%) of these 51 individuals were made non-inducible.

An ICD was implanted in 11 out of 14 inducible patients and 5 out of 37 non-inducible patients. 10 out of 86 patients experienced VT recurrence after a median follow-up of 40 months (Q1-Q3: 24-70 months). One patient with ICD passed away unexpectedly, and the total mortality rate was 27%.

No SCD or VT recurrence happened among the 37 patients (none on antiarrhythmic medications) with LVEF >35%, tolerated VT, and non-inducibility. There was no SCD among the 14 patients with LVEF >35%, tolerated VT, and inducibility following ablation, yet, 29% of them experienced VT recurrence.

Overall, the prognosis for modern post-MI patients who have stable coronary disease, LVEF >35%, tolerated VT, no signs of hemodynamic compromise, and are noninducible following functional substrate ablation is favorable. In these particular patients, it appears to be safe to forego ICD installation.

Source:

Rademaker, R., de Riva, M., Piers, S. R. D., Wijnmaalen, A. P., & Zeppenfeld, K. (2024). Excellent Outcomes After First-Line Ablation in Post-MI Patients With Tolerated VT and LVEF >35%. In JACC: Clinical Electrophysiology (Vol. 10, Issue 11, pp. 2303–2311). Elsevier BV. https://doi.org/10.1016/j.jacep.2024.06.027