Early vs. delayed vt ablation in patients with ischemic cardiomyopathy

Abstract Background Despite Ventricular tachycardia (VT) ablation having been shown to reduce the recurrence of VT episodes, the timing of performing VT ablation (early; at the time of ICD implantation) or (deferred: after the patient has received ICD shocks) remains debatable. Objective To conduct a systematic review and meta-analysis of published data from randomized controlled trials (RCTs) in patients with ischemic cardiomyopathy (ICM) with the aim of comparing outcomes of VT ablation stratified by procedural timing. Methods We conducted a meta-analysis of 6 landmark RCTs which included patients with ischemic cardiomyopathy who were either at high risk of VT or experienced VT+ICD shocks. The primary outcomes of recurrence of VT and/or VT storm were compared according to the timing of the VT ablation procedure (early vs. deferred). The secondary outcome of ICD shocks was also compared. Sensitivity analyses in a subgroup of patients with left ventricular ejection fraction (LVEF) of > 30% was performed. Results Following a comprehensive search strategy, a total of 6 RCTs were included in the final analysis. Based on the pooled analyses, "early VT ablation" was associated with a significant reduction in the primary outcome of recurrent VT episodes (pooled OR of 0.63, 95% CI of 0.48-0.84, p < 0.05) compared to the "deferred VT ablation" strategy. Furthermore, the effect size of impact of early VT ablation was more pronounced in patients with preserved LVEF > 30% (pooled OR of 0.55, 95% CI of 0.41-0.73, p = 0.01) compared to the deferred VT ablation approach (Figure 1). Early VT ablation was also associated with a decreased risk of ICD shocks (pooled OR of 0.59, 95% CI of 0.45-0.76) compared to the deferred approach (Figure 2). Conclusions The findings of this pooled meta-analysis of 6 major RCTs suggest that an earlier timing of VT ablation may be more beneficial in reducing recurrent VT, electrical storm and ICD shocks. The benefits of earlier VT ablation appear to be more pronounced in the subset of patients with LVEF of > 30% and ICM.