Role of ventricular tachycardia cycle length in the outcomes after catheter ablation or antiarrhythmic drugs in the SURVIVE-VT trial

Abstract Background It has been suggested that antiarrhythmic drugs (AAD) are less effective and safe in slow ventricular tachycardia (VT) due to their effect on conduction velocity, which could stabilize reentry. Conversely, catheter ablation aims to disrupt the VT circuit. Because of the distinct mechanisms of action of AAD and catheter ablation on the VT circuit, VT cycle length (VT-CL) may play a crucial role in determining their therapeutic efficacy. Therefore, VT-CL could be important in selecting VT treatment. Purpose The aim of this study was to assess the impact of VT-CL on outcomes following catheter ablation or antiarrhythmic drugs in AAD-naïve patients with ischemic cardiomyopathy presenting with VT. Methods This is a post hoc analysis of the previously published Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia (SURVIVE-VT) trial. In summary, 144 patients with ischemic cardiomyopathy and symptomatic VT were randomized to receive either catheter ablation (N=71) or AAD (N=73) as first-line therapy. We analyzed VT recurrence, implantable cardioverter-defibrillator (ICD) therapies, and the incidence of slow/incessant VT/VT storm using Cox proportional hazard models, with treatment and VT-CL interaction terms, adjusted for age. Missing VT-CL data for five patients were imputed using the median value. Results In patients with chronic ischemic heart disease and VT treated with either AAD or catheter ablation, a significant interaction was observed between clinical VT-CL and treatment effect on VT recurrence (p=0.016 for the interaction). Specifically, slower VT cycle lengths were associated with higher rates of VT recurrence (hazard ratio per 10 ms [HR] 1.094, 95% confidence interval [CI] 1.015, 1.179; p=0.037) in patients treated with AAD, while no significant effect was observed in those undergoing catheter ablation (see Figure 1). Survival freedom from VT recurrence in patients with VT-CL ≥300ms was significantly higher in patients treated with catheter ablation (78.8% vs 58.1%, log-rank p=0.044, see Figure 2). As expected, VT-CL was significantly associated with a higher risk of slow/incessant VT/VT storm (HR per 10 ms 1.115, 95% CI 1.017-1.222, p=0.047) but was not associated with ICD therapies (HR per 10 ms 1.082, 95% CI 0.994-1.178, p=0.102). Conclusion VT-CL significantly influences treatment outcomes, with slower VT cycles associated with an increased risk of VT recurrence in patients treated with AAD, but not in those undergoing catheter ablation. Therefore, VT-CL should be taken into consideration when selecting the optimal therapy for patients with ischemic cardiomyopathy and VT.Figure 1Figure 2