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Catheter Ablation of Ventricular Tachycardia as the First-Line Therapy in Patients With Coronary Artery Disease and Preserved Left Ventricular Systolic Function: Long-Term Results MARCELL CLEMENS, M.D., Ph.D., PETR PEICHL, M.D., Ph.D., DAN WICHTERLE, M.D., ˇ PAVLU, ˇ AK, ´ M.D., Ph.D., BASHAR ALDHOON, M.D., Ph.D., ˚ M.D., ROBERT CIH Ph.D., LUDEK and JOSEF KAUTZNER, M.D., Ph.D. From the Klinika kardiologie, IKEM, Praha, Czech Republic

VT Ablation in Patients With Preserved LV Function. Introduction: Patients with coronary artery disease (CAD), relatively preserved left ventricular ejection fraction (LVEF), and hemodynamically tolerated ventricular tachycardia (VT) may benefit from catheter ablation as the first-line treatment. Our aim was to analyze the long-term results of VT ablation in this population. Methods and Results: Thirty-one patients (1 woman, mean age 67 ± 10 years) with CAD, tolerated VT, and LVEF ࣙ40% underwent catheter ablation as the first-line treatment of the arrhythmia. Catheter ablation was performed in order to abolish all inducible VTs. An ICD was implanted if sustained VT of any morphology remained inducible after the procedure. The mean LVEF was 48 ± 6% and the mean VT cycle length reached 348 ± 70 milliseconds in the study cohort. Clinical and all inducible VTs were abolished in 90% (28/31) and 58% (18/31) of the patients, respectively. An ICD was subsequently implanted in 42% of cases. Over a mean follow-up of 3.8 ± 2.9 years, 42% (13/31) patients died. Survival of the patients with or without the ICD was not significantly different (P = 0.47). VT recurrence was observed in 11% (2/18) of patients who had complete elimination of all inducible VTs. No sudden death occurred in patients without the ICD. Conclusions: Catheter ablation of VT as the first-line treatment in patients with CAD and relatively preserved LVEF is a viable strategy. It may prevent implantation of the ICD in a considerable proportion of patients. Abolition of all inducible VTs confers low VT recurrence rate over a long-term follow-up. (J Cardiovasc Electrophysiol, Vol. 26, pp. 1105-1110, October 2015) catheter ablation, implantable cardioverter defibrillator, long-term survival, preserved left ventricular function, ventricular tachycardia Introduction Prognosis of patients with coronary artery disease (CAD) and sustained monomorphic ventricular tachycardia (VT) is generally considered to be poor and the implantation of an implantable cardioverter-defibrillator (ICD) as a secondary prevention is recommended by current guidelines.1 However, major ICD trials2-4 excluded patients with hemodynamically stable VT and left ventricular ejection fraction (LVEF) >40%. Recommendations for such cases are based on the results of small studies that showed either a high total mortality in these patients or a high prevalence of fast VTs during follow-up after ICD implantation.5-8 Currently, catheter ablation of CAD-related VTs is recommended mostly as an adjunctive treatment to ICD implant. Dr. Kautzner serves as consultant/advisory board member for Biosense Webster, Boston Scientific, Medtronic, and St. Jude Medical. Other authors: No disclosures. Address for correspondence: Marcell Clemens, Klinika kardiologie, IKEM, V´ıdeˇnsk´a 1958/9, Praha 4, 140 21, Czech Republic. Fax: 3652414928; E-mail: [email protected] Manuscript received 21 March 2015; Revised manuscript received 13 May 2015; Accepted for publication 19 June 2015. doi: 10.1111/jce.12751

The ICD, however, does not eliminate the substrate responsible for VT and implantation alone without catheter ablation carries a higher risk of arrhythmia recurrences.9,10 Moreover, recent publications suggested that catheter ablation without the ICD backup might be a reasonable option for selected post-MI patients with a low incidence of sudden cardiac death during follow-up.11,12 The aim of this study is to analyze the results of catheter ablation as the first-line therapy in patients with CAD, relatively preserved (ࣙ40%) LVEF, and hemodynamically stable VT. Methods Study Population A total of 573 VT ablations were performed in 455 patients with structural heart disease in our institution between June 2001 and November 2013. Patients were included in this study if they had a history of CAD and presented with hemodynamically tolerated monomorphic VT and relatively preserved (ࣙ40%) LVEF. CAD was defined as a history of myocardial infarction (MI) or history of revascularization due to significant stenosis of coronary artery. Survivors of cardiac arrest or subjects with a history of hemodynamically unstable VT were excluded. A total of 31 patients (7%) were identified fulfilling enrollment criteria. Ablation procedures were therefore performed over more than 12 years. The

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number of patients enrolled within consecutive quartiles of this period was 4, 4, 9, and 14, respectively. The study was approved by the institutional ethics committee. Catheter Ablation Procedure Informed consent was obtained from all patients. The procedure was performed under conscious sedation with the use of midazolam and alfentanyl. Systemic anticoagulation was achieved for left ventricular mapping using intravenous heparin with a target ACT of 300–350 seconds. Our regular catheter setup for a structural VT ablation consisted of a quadripolar catheter positioned in the right ventricular apex and a 4 or 8 mm tip nonirrigated ablation catheter before 2004 (in 4 patients) or an irrigated 3.5 mm tip catheter (NAVISTARTM , Biosense-Webster, Diamond Bar, CA, USA) afterward. In selected patients, the procedure was facilitated by intracardiac echocardiography (ICE, Accunav, Siemens). At baseline, programmed stimulation up to 3 extrastimuli from the 2 right ventricular sites was performed to induce VTs, which were subsequently targeted during the mapping. Left ventricular access was achieved either retrogradely through aorta or via a transseptal puncture. An integrated approach to substrate mapping was employed.13 In principle, a 3D voltage map of the left and/or right ventricle was obtained in sinus rhythm using electroanatomical mapping system (CARTO XPTM and CARTO3TM , Biosense-Webster), identifying low-voltage areas in the ventricle. In addition, late potentials or abnormal fractionated electrograms were tagged within the map. Pacing at minimum threshold was used in these sites to evaluate activation delay (stimulus to QRS interval) and associated morphology of the QRS complex. In case of induction of hemodynamically tolerated VT, entrainment mapping was performed in sites previously identified as zones of slow conduction. Sites of concealed entrainment were tagged within the voltage map. Zones of late potentials and/or slow conduction were targeted by radiofrequency current with an intention to abolish abnormal signals or achieve noncapture at ablation sites. In case of tolerated VT, ablation was performed within the critical isthmus identified by entrainment mapping, followed by additional substrate modification. Radiofrequency energy was set between 30 and 40 W with a flow rate of 30 mL/min for irrigated catheters. During ablation, the proper tissue contact was monitored by fluoroscopy or by ICE. The endpoint of the procedure was a noninducibility of any sustained monomorphic VT or polymorphic VT. Noninducibility was tested using 2 drive cycles (600 milliseconds and 400 milliseconds) with up to triple extrastimuli (minimum coupling interval of 200 milliseconds) from RV apex and RV outflow tract. A procedure was considered to be completely successful if no VT was inducible and partially successful, if the clinical tachycardia was eliminated, but other morphologies including ventricular fibrillation were still inducible after ablation. Complications were detected using departmental tracking system that documents any significant complication associated with prolongation of hospital stay or death, and/or necessitating additional intervention. Postablation Management In patients with partially successful catheter ablation, implantation of an ICD was performed.

Ventricular tachycardia detection threshold was programmed 30–40 milliseconds above the cycle length of the clinical tachycardia. In the 13 patients receiving ICDs, 2-zone tachycardia detection was programmed in 12; VT detection threshold was set from 410 to 330 milliseconds (mean 370 ± 38 milliseconds) depending on the cycle length of the clinical tachycardia. VF detection was set from 300 to 260 milliseconds. The number of intervals detected were left on the default setting of the devices. ATPs and shocks were programmed both for VT and VF zones, but the number and type of ATPs and the energy of shocks in each zone were left to physician discretion. Follow-up visits were scheduled every 3–12 months on an outpatient basis, depending on patients’ clinical status. Survival in all patients was validated by a review of national citizen registry. Data on ICD therapies were obtained from out-patient clinical records. Statistics Continuous variables were reported as means (SD) or in the case of non-Gaussian data as median (interquartile range). Categorical variables were expressed as percentages. Comparison of groups was performed using unpaired t-test, nonparametric Mann–Whitney test for continuous variables and chi-square or Fisher exact tests for categorical variables, as appropriate. Survival was displayed using Kaplan–Meier curves and intergroup differences were analyzed by log-rank test. All tests were 2-tailed and a P value < 0.05 was regarded statistically significant. Results Study Population The mean age of the study population was 67 ± 10 years with substantial male predominance (97%; 30/31). The mean LVEF was 48 ± 6%. A total of 65% of patients (20/31) had a history of MI and VT occurred after a mean interval of 140 ± 118 months after the MI. The rest of the population underwent myocardial revascularization for significant coronary artery stenosis and presented subsequently with VT. The mean cycle length of the clinical arrhythmia was 348 ± 70 milliseconds. VT Ablation During programmed electrical stimulation, a mean of 1.6 VT morphologies (range of 1–4) were inducible per patient. In the majority of patients (65%, 20/31), endocardial scar was detectable during electroanatomical mapping in the inferior wall of the left ventricle. Anterior or apical scar was found in 19% (6/31) and lateral scar in 16% (5/31) of the cases. Irrigated tip was used in 87% (27/31) of patients. Mean procedure time and fluoroscopy time reached 205 ± 70 minutes and 15 ± 11 minutes, respectively. Mean duration of radiofrequency applications was 998 ± 682 seconds. Clinical VT was successfully eliminated in 28/31 (90%). Complete noninducibility of VT was achieved in 58% (18/31) of the study cohort. Interestingly, critical zones of slow conduction for at least one inducible VT were found in the right ventricle in a high proportion of patients (23%, 7/31). In these cases, catheter ablation was performed also in the right ventricle. This scenario was observed exclusively in patients after inferior MI. No major complications related to the procedure

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Figure 1. Ventricular tachycardia ablation was completely successful with the elimination of all inducible tachycardias in 18/31 patients. In this cohort ICD implantation was rarely necessary over a long-term follow-up. However, in patients with partially successful ablation, VT recurrence was common and reablation was frequently required.

TABLE 1

TABLE 2

Baseline Patient Characteristics

Details of Ventricular Tachycardia Ablation

Ablation Only (n = 18) Mean age (years) Gender (female) Follow-up (years) CL of VT (milliseconds) LVEF (%) LVEDD (mm)

70 ± 0 3.9 ± 330 ± 49 ± 57 ±

9 3.3 45 7 7

Ablation + ICD (n = 13) 62 ± 1 3.7 ± 360 ± 48 ± 59 ±

9 2.3 80 5 5

P 0.02 0.42 0.85 0.26 0.59 0.31

CL = cycle length; LVEDD = left ventricular end-diastolic diameter; EF = left ventricular ejection fraction; ICD = implantable cardioverter defibrillator; LV = left ventricle; RF = radiofrequency; VT = ventricular tachycardia.

were recorded, except for one patient with preprocedural bifascicular block in whom the ablation at the proximal septum resulted in complete AV block. The patient was implanted with a system for cardiac resynchronization therapy. The outcome and follow-up of patients after catheter ablation are summarized in Figure 1. The ICD was implanted in 13 patients after a median time of 4 (range of 2–8) days because of unsuccessful or partially successful VT ablation. The ICD was also implanted in 2 additional patients with successful ablation. In one patient, the device was implanted 48 days after the procedure for recurrent fast VT. In the other patient, implantation of ICD was performed 288 days after the VT ablation due to conventional bradycardia indication and worsening of LVEF. Baseline characteristics of patients with and without an ICD are presented in Table 1. The procedural details of VT ablations of the 2 subgroups of patients are presented in Table 2. Both subgroups did not differ significantly in any of assessed parameters, except the necessity of reablation during follow-up. This reflects high VT recurrence rate in patients with failed ablation procedure.

Procedure time (minutes) Fluoroscopy time (minutes) Hemodynamically unstable VTs inducible prior ablation (%) RF ablation time (seconds) Scar location (%) Inferior Noninferior Reablation (%) Epicardial access required to suppress VT recurrences (%) Ablation in right ventricle (%)

Ablation Only (n = 18)

Ablation + ICD (n = 13)

P

193 ± 73 12 ± 9 3 (17)

222 ± 67 20 ± 13 7 (54)

0.267 0.063 0.03

900 ± 732

1134 ± 638

0.365

9 (50) 9 (50) 0 0

11 (85) 2 (15) 6 (46) 2 (15)

0.066 0.006 0.168

4 (22)

3 (23)

0.95

ICD = implantable cardioverter defibrillator; RF = radiofrequency VT = ventricular tachycardia.

Long-Term Follow-Up of Patients Over a mean follow-up of 3.8 ± 2.9 years, 42% (13/31) patients died. Kaplan–Meier survival curves depicting allcause mortality did not show significant difference between patients with and without ICD (log rank, P = 0.47) (Fig. 2). None of patients without the ICD died suddenly, although the exact mode of death was not available in one patient. Two patients had arrhythmia recurrence after successful VT ablation with elimination of all inducible VTs (Fig. 3). Both had hemodynamically stable monomorphic VTs. An ICD was implanted in one and amiodarone was started in the other since the patient refused implantation of an ICD. Interestingly, a high prevalence of appropriate therapies was observed (54%; 7/13) in patients implanted with an ICD. Spontaneous tachycardia episodes retrieved from device memory were mostly monomorphic VTs with mean CL of

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(2) Despite relatively smaller extent of myocardial scar in this patient population, the arrhythmogenic substrate was in many cases quite complex, requiring either right ventricular or epicardial ablation. (3) Successful catheter ablation prevented ICD implantation in more than half of the cases. (4) Complete elimination of all inducible VTs conferred a good prognosis with a low arrhythmia recurrence rate during follow-up. (5) Long-term survival did not differ between patients with or without an ICD. Prognostic Significance of Hemodynamically Stable VT in Structural Heart Disease Figure 2. All-cause mortality is similar in patients with and without an implanted cardioverter defibrillator during long-term follow-up.

Figure 3. Recurrence of ventricular tachycardia/fibrillation is less common after successful VT ablation (in patients without an ICD) compared to patients with only partial elimination of all inducible tachycardias (with ICDs). Only hemodynamically stable, monomorphic VT episodes were observed after successful VT ablation.

320 milliseconds (range: 260–410 milliseconds). Episodes of polymorphic VT/ventricular fibrillation were also recorded in 2 patients. Appropriate ATPs and shocks were delivered in 4 patients, while VTs were treated with ATPs only in 3. Due to recurrent VT episodes and ICD therapies, 6 patients had repeated ablation, of them 2 had arrhythmogenic substrate localized epicardially. It was successfully ablated via subxiphoid approach in one patient. The other patient had previous coronary artery bypass surgery and underwent successful surgical ablation via sternotomy. Importantly, arrhythmia recurrence rate was very low in patients with completely elimination of inducible VTs during the index procedure. Only 2/18 (11%) of these patients had recurrent VTs during follow-up. Decision on the use of antiarrhythmic medication was left on discretion of their cardiologist. At hospital discharge, 33% (6/18) and 46% (6/13) of patients with successful ablation and ICD group, respectively, were treated with amiodarone. The rate of amiodarone use remained similar during follow-up. Discussion The main findings of our study can be summarized as follows: (1) Clinical, hemodynamically tolerated VT in patients with CAD and relatively preserved LVEF can be abolished by catheter ablation nearly in all cases. However, suppression of all inducible VTs was less likely (achieved in 58% of cases).

Hemodynamically tolerated VTs in patients with CAD are not considered prognostically benign. The first observation, indicating their adverse prognostic impact, was presented by Bocker et al. They reported a 22% incidence of fast VTs in a cohort of 50 patients implanted with ICD following clinical presentation of well-tolerated monomorphic VT.7 Further evidence was derived from the analysis of the AVID Registry data that reported similar mortality rates of the 440 patients with stable and the 1029 patients with unstable VT (33.6% and 27.6% at 3 years, respectively). Authors concluded that well-tolerated slow VT could be a marker of an arrhythmia substrate capable producing also malignant, fast tachycardias.6 This assumption was also supported by a more recent study by Glikson et al., who reported a 12% incidence of hemodynamically unstable VT over a mean follow-up of 23.6 months in 82 patients implanted with ICD for tolerated VTs.8 These studies helped to establish the indication of ICD in patients with structural heart disease and welltolerated VT. Importantly, the mean LVEF in these studies ranged between 32 ± 11% and 39 ± 16%, indicating that patients with LVEF 30%.9 In this context, the concept of the first-line ablation therapy without an ICD backup is of a great interest. Patients with stable CAD and limited postinfarction scar may have well-defined arrhythmogenic substrate that can be potentially modified by catheter ablation. In general, catheter ablation may be offered as the firstline approach when 2 main prerequisites are fulfilled. First, the method has to be able to minimize effectively risk of arrhythmia recurrences. Second, the success of ablation has to be maintained long term. Recently, Pauriah et al.11

Clemens et al.

reported a stepwise approach to the management of post-MI VTs. VT ablation as the first-line therapy was performed in 45 post-MI patients with monomorphic VT followed by an electrophysiological study within the subsequent 3 months. A total of 26 (58%) patients did not receive an ICD due to noninducibility of any VT at the end of VT ablation and also during the subsequent electrophysiological study. Over a median follow-up of 4.5 years, all-cause mortality reached 31.1% in the entire cohort. No difference was observed in patients with or without an ICD. Importantly, only one case of sudden death was reported in a cohort treated with ablation only. Although this report is similar to our study regarding the total mortality and similar survival of patients with and without ICD, some important differences to current study design can be emphasized: Pauriah et al. included patients regardless of their LVEF and the tolerability of the VTs. Our results are in a concordance with the above study. The study showed that catheter ablation as the first-line therapy could prevent ICD implantation in more than half of the patients. Although catheter ablation was very effective in the elimination of the clinical VT, the ability to abolish all inducible VTs was lower. One possible explanation may be the more extensive arrhythmogenic substrate and the involvement of the interventricular septum and/or epicardium in some patients. A recent study investigating the arrhythmogenic substrate for post-MI VTs showed that patients with septal involvement may have right ventricular sites that are critical for one of the inducible VTs and that those arrhythmias cannot be abolished by left ventricular ablation alone.16 Of note, the right ventricular ablation was required for one of the inducible VTs in more than one-fifth of our patient cohort, and epicardial ablation had to be performed for arrhythmia suppression in 2 patients. This was more commonly observed in patients after inferior infarction. It may be explained, however, by the selection bias due to the fact that patients after anterior MI with extensive septal involvement had likely low LVEF and, thus, were not included in our study.

Long-Term Survival After Catheter Ablation Besides the ability of ablation to abolish VTs acutely, the long-term post-ablation prognosis of CAD patients with tolerated VTs and relatively preserved LVEF remains unclear. In this respect, Maury et al.12 reported outcome of catheter ablation without subsequent ICD backup in a large population of patients with structural heart disease, LVEF over 30% and tolerated monomorphic VT. The authors found a very low (2.4%) rate of sudden cardiac death over a mean follow-up of 32 ± 27 months. Similarly to our result, in their study there was no difference in survival between patients with and without an ICD. These data suggest that the given population has very low risk of malignant arrhythmias. Interestingly, the all-cause annual mortality rate was higher in our study (11% vs. 4.5%), but was more similar to mortality rates reported in CAD patients in a recent large registry.17 The difference in mortality rates may be explained by the higher age of our patients and the fact that the study of Maury et al. included a mixed cohort of patients with different etiologies of cardiomyopathy. Furthermore, Maury et al. included only selected patients that were primarily discharged after ablation without an ICD; the patients that underwent ICD implantation despite catheter ablation were not included and

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the control group presented in the study contained patients that did not undergo catheter ablation. Programmed ventricular stimulation is widely used to assess the acute success of ventricular tachycardia ablation. However, beyond the probabilistic nature of the test, lesion maturation or a possible change in antiarrhytmic drugs after ablation raise further concerns about its long-term predictive value. Despite the theoretical considerations, the predictive value of programmed stimulation after VT ablation in patients with structural (especially ischemic) heart disease is reasonable.18-20 In a recent cohort of patients with structural heart disease undergoing VT ablation, postablation programmed stimulation testing had an excellent negative predictive value: only 4.5% of patients with a negative test had recurrent VT during a follow-up of 4.5 years.11 Moreover, in a recent metaanalysis summarizing data of 928 patients, noninducibility of VT after VT ablation conferred an improved arrhythmia-free survival and lower all-cause mortality.21 Our study confirms that patients with inducible ventricular arrhythmia after ablation had frequent arrhythmia recurrences over the follow-up period. On the contrary, patients with complete elimination of all inducible VTs during catheter ablation had reasonably good long-term prognosis. These observations confirm the results of the abovementioned studies which, despite some criticism, showed that programmed stimulation remains a valuable tool in risk stratification after VT ablation. Limitations This study is not a randomized controlled trial, and therefore the inherent limitations of observational studies do apply. In addition, it is a small study with nonhomogeneous study groups. The decision on implantation of an ICD was not random but based on a decision tree. The programming of the ICD after implantation was not unified. It is conceivable that the patient group without an ICD represented a healthier cohort that could have even better survival with an ICD. Additionally, an irrigated tip was not used for all ablation procedures, possibly influencing the result in substrate modification. The results of this observational study need to be verified in a randomized controlled trial. However, given the low incidence of tolerated VT in patients with CAD and preserved LVEF, the recruitment of patients for such a trial could be challenging. Conclusions Patients with CAD, hemodynamically tolerated VT, and relatively preserved LVEF have low risk for arrhythmia recurrence after successful VT ablation. In such cases, VT ablation as the first-line treatment may be a reasonable approach that can prevent ICD implantation in considerable proportion of patients. References 1. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (Writing committee to revise the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices) developed in collaboration with the American Association of

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Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 2008;51:e1-e62. AVID Investigators: A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near fatal ventricular arrhythmias: The Antiarrhythmics Versus Implantable Defibrillators (AVID) Investigators. N Engl J Med 1997;337:15761583. Connolly SJ, Gent M, Roberts RS, Dorian P, Roy D, Sheldon RS, Mitchell LB, Green MS, Klein GJ, O’Brien B: Canadian Implantable Defibrillator Study (CIDS): A randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation 2000;101:12971302. Kuck KH, Cappato R, Siebels J, Ruppel R: Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: The Cardiac Arrest Study Hamburg (CASH). Circulation 2000;102:748-754. Sarter BH, Finkle JK, Gerszten RE, Buxton AE: What is the risk of sudden cardiac death in patients presenting with hemodynamically stable sustained ventricular tachycardia after myocardial infarction? J Am Coll Cardiol 1996;28:122-129. Raitt MH, Renfroe EG, Epstein AE, McAnulty JH, Mounsey P, Steinberg JS, Lancaster SE, Jadonath RL, Hallstrom AP; for the Antiarrhythmics Versus Implantable Defibrillator Investigators: “Stable” ventricular tachycardia is not a benign rhythm: Insights from the Antiarrhythmics versus Implantable Defibrillators (AVID) Registry. Circulation 2001;103:244-252. Bocker D, Block M, Isbruch F, Fastenrath C, Castrucci M, Hammel D, Scheld HH, Borggrefe M, Breithardt G: Benefits of treatment with implantable cardioverter-defibrillators in patients with stable ventricular tachycardia without cardiac arrest. Br Heart J 1995;73:158-163. Glikson M, Lipchenca I, Viskin S, Ballman KV, Trusty JM, Gurevitz OT, Luria DM, Eldar M, Hammill SC, Freidman PA: Long-term outcome of patients who received implantable cardioverter defibrillators for stable ventricular tachycardia. J Cardiovasc Electrophysiol 2004;15:658-664. Kuck KH, Schaumann A, Eckardt L, Willems S, Ventura R, Delacr´etaz E, Pitschner HF, Kautzner J, Schumacher B, Hansen PS; VTACH study group: Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): A multicentre randomised controlled trial. Lancet 2010;375:31-40. Reddy VY, Reynolds MR, Neuzil P, Richardson AW, Taborsky M, Jongnarangsin K, Kralovec S, Sediva L, Ruskin JN, Josephson ME: Prophylactic catheter ablation for the prevention of defibrillator therapy. N Engl J Med 2007;357:2657-2665. Pauriah M, Cismaru G, Magnin-Poull I, Andronache M, Sellal JM, Schwartz J, Brembilla-Perrot B, Sadoul N, Aliot E, de Chillou C: A stepwise approach to the management of postinfarct ventricular tachycardia using catheter ablation as first-line treatment: A single-center experience. Circ Arrhythm Electrophysiol 2013;6:351-356. Maury P, Baratto F, Zeppenfeld K, Klein G, Delacretaz E, Sacher F, Pruvot E, Brigadeau F, Rollin A, Andronache M, Maccabelli G, Gawrysiak M, Brenner R, Forclaz A, Schlaepfer J, Lacroix D, Duparc A, Mondoly P, Bouisset F, Delay M, Hocini M, Derval N, Sadoul N, Magnin-Poull I, Klug D, Haissaguerre M, Jais P, Della Bella P, de Chillou C: Radio-frequency ablation as primary management of well tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%. Eur Heart J 2014;35:1479-1485.

13. Kautzner J, Cih´ak R, Peichl P, Vancura V, Bytesn´ık J: Catheter ablation of ventricular tachycardia following myocardial infarction using threedimensional electroanatomical mapping. Pacing Clin Electrophysiol 2003;26(Pt 2):342-347. 14. Domanski MJ, Sakseena S, Epstein AE, Hallstrom AP, Brodsky MA, Kim S, Lancaster S, Schron E; for the AVID Investigators: Relative effectiveness of the implantable cardioverter-defibrillator and antiarrhythmic drugs in patients with varying degrees of left ventricular dysfunction who have survived malignant ventricular arrhythmias. J Am Coll Cardiol 1999;34:1090-1095. 15. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B: American College of Cardiology; American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association; Heart Rhythm Society: ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace 2006;8:746-837. 16. Yokokawa M, Good E, Crawford T, Chugh A, Pelosi F Jr, Latchamsetty R, Oral H, Morady F, Bogun F: Value of right ventricular mapping in patients with postinfarction ventricular tachycardia. Heart Rhythm 2012;9:938-942. 17. Sacher F, Tedrow UB, Field ME, Raymond JM, Koplan BA, Epstein LM, Stevenson WG: Ventricular tachycardia ablation: Evolution of patients and procedures over 8 years. Circ Arrhythm Electrophysiol 2008;1:153-161. 18. O’Donnell D, Bourke JP, Furniss SS: Standardized stimulation protocol to predict the long-term success of radiofrequency ablation of postinfarction ventricular tachycardia. Pacing Clin Electrophysiol 2003; 26(Pt 2):348-351. 19. Frankel DS, Mountantonakis SE, Zado ES, Anter E, Bala R, Cooper JM, Deo R, Dixit S, Epstein AE, Garcia FC, Gerstenfeld EP, Hutchinson MD, Lin D, Patel VV, Riley MP, Robinson MR, Tzou WS, Verdino RJ, Callans DJ, Marchlinski FE: Noninvasive programmed ventricular stimulation early after ventricular tachycardia ablation to predict risk of late recurrence. J Am Coll Cardiol 2012;59:1529-1535. 20. Carbucicchio C, Santamaria M, Trevisi N, Maccabelli G, Giraldi F, Fassini G, Riva S, Moltrasio M, Cireddu M, Veglia F, Della Bella P: Catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-defibrillators: Short- and long-term outcomes in a prospective single-center study. Circulation 2008;117:462-469. 21. Ghanbari H, Baser K, Yokokawa M, Stevenson W, Della Bella P, Vergara P, Deneke T, Kuck KH, Kottkamp H, Fei S, Morady F, Bogun F: Noninducibility in postinfarction ventricular tachycardia as an end point for ventricular tachycardia ablation and its effects on outcomes: A meta-analysis. Circ Arrhythm Electrophysiol. 2014;7:677683.

Catheter Ablation of Ventricular Tachycardia as the First-Line Therapy in Patients With Coronary Artery Disease and Preserved Left Ventricular Systolic Function: Long-Term Results.

Patients with coronary artery disease (CAD), relatively preserved left ventricular ejection fraction (LVEF), and hemodynamically tolerated ventricular...
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