• John L Sapp, TangAnthony S LASLFrom the QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P., A.A.), Western University, London, ON (A.S.L.T., L.J.G.), the Population Health Research Institute (J.S.H.) and Hamilton Health Sciences Centre (G.A.), Ratika Parkash, William G Stevenson, Jeff S Healey, Lorne J Gula, Girish M Nair, Vidal Essebag, Lena Rivard, Jean-Francois Roux, Pablo B Nery, Jean-Francois Sarrazin, Guy Amit, Jean-Marc Raymond, Marc Deyell, Chris Lane, Frederic Sacher, Christian de Chillou, Vikas Kuriachan, Amir AbdelWahab, Isabelle Nault, Katia Dyrda, Stephen Wilton, Umjeet Jolly, Arvindh Kanagasundram, George A Wells, and VANISH2 Study Team.
• From the QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P., A.A.), Western University, London, ON (A.S.L.T., L.J.G.), the Population Health Research Institute (J.S.H.) and Hamilton Health Sciences Centre (G.A.), Hamilton, ON, the University of Ottawa Heart Institute (G.M.N., P.B.N.), the McGill University Health Centre (V.E.), the Montreal Heart Institute (L.R., K.D.), and Centre Hospitalier de l'Universitaire de Montreal (J.-M.R.), Montreal, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (J.-F.R.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec (J.-F.S., I.N.), the University of British Columbia, Vancouver (M.D.), Kelowna General Hospital, Kelowna, BC (C.L.), the University of Ottawa, Ottawa (G.A.W.), and the University of Calgary, Calgary, AB (V.K., S.W.) - all in Canada; Vanderbilt University Medical Center, Nashville (W.G.S., A.K.); Centre Hospitalier Universitaire de Bordeaux, L'institut des Maladies du Rythme Cardiaque, Bordeaux (F.S.), and Centre Hospitalier Universitaire de Nancy, Nancy (C.C.) - both in France; and St. Mary's General Hospital, Passaic, NJ (U.J.).
• N. Engl. J. Med. 2024 Nov 16.

BackgroundPatients with ventricular tachycardia and ischemic cardiomyopathy are at high risk for adverse outcomes. Catheter ablation is commonly used when antiarrhythmic drugs do not suppress ventricular tachycardia. Whether catheter ablation is more effective than antiarrhythmic drugs as a first-line therapy in patients with ventricular tachycardia is uncertain.MethodsIn an international trial, we randomly assigned in a 1:1 ratio patients with previous myocardial infarction and clinically significant ventricular tachycardia (defined as ventricular tachycardia storm, receipt of appropriate implantable cardioverter-defibrillator [ICD] shock or antitachycardia pacing, or sustained ventricular tachycardia terminated by emergency treatment) to receive antiarrhythmic drug therapy or to undergo catheter ablation. All the patients had an ICD. Catheter ablation was performed within 14 days after randomization; sotalol or amiodarone was administered as antiarrhythmic drug therapy according to prespecified criteria. The primary end point was a composite of death from any cause during follow-up or, more than 14 days after randomization, ventricular tachycardia storm, appropriate ICD shock, or sustained ventricular tachycardia treated by medical intervention.ResultsA total of 416 patients were followed for a median of 4.3 years. A primary end-point event occurred in 103 of 203 patients (50.7%) assigned to catheter ablation and in 129 of 213 (60.6%) assigned to drug therapy (hazard ratio, 0.75; 95% confidence interval, 0.58 to 0.97; P = 0.03). Among patients in the catheter ablation group, adverse events within 30 days after the procedure included death in 2 patients (1.0%) and nonfatal adverse events in 23 patients (11.3%). Among the patients assigned to drug therapy, adverse events that were attributed to antiarrhythmic drug treatment included death from pulmonary toxic effects in 1 patient (0.5%) and nonfatal adverse events in 46 patients (21.6%).ConclusionsAmong patients with ischemic cardiomyopathy and ventricular tachycardia, an initial strategy of catheter ablation led to a lower risk of a composite primary end-point event than antiarrhythmic drug therapy. (Funded by the Canadian Institutes of Health Research and others; VANISH2 ClinicalTrials.gov number, NCT02830360.).Copyright © 2024 Massachusetts Medical Society.

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