Title: Catheter Ablation of Stable Ventricular Tachycardia Before Defibrillator Implantation in Patients With Coronary Heart Disease (VTACH): A Multicentre Randomised Controlled Trial
Topic: Arrhythmias
Date Posted: 1/14/2010
Author(s): Kuck KH, Schaumann A, Eckardt L, et al., on behalf of the VTACH Study Group.
Citation: Lancet 2010;375:31-40.
Clinical Trial: yes
Study Question: What is the clinical value of prophylactic radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) before implantation of an implantable cardioverter/defibrillator (ICD)?
Methods: One hundred seven patients (mean age 66 years) with stable VT, prior myocardial infarction (MI), and an ejection fraction ≤50% (mean 34%) were randomly assigned to undergo RFCA plus ICD implantation (n = 52) or only ICD implantation (n = 55). Stored electrograms were analyzed to identify VT events during follow-up. Quality of life was measured at each clinic visit. The 1° endpoint was time to first episode of VT/ventricular fibrillation.
Results: Approximately 30% of patients in both groups received amiodarone during follow-up, and the mean follow-up duration was 22 months. The first episode of VT occurred at a median follow-up of 18.6 months in the ablation group, compared to only 5.9 months in the control group. Cardiac hospitalizations were significantly reduced in the ablation group compared to the control group (67% vs. 45%, respectively, at 24 months), but there were no significant differences in mortality or quality of life. The mean number of appropriate ICD shocks per patient per year was 0.6 in the ablation group and a significantly higher 3.4 in the control group.
Conclusions: RFCA of VT significantly reduces the incidence of VT during follow-up in post-MI patients treated with an ICD.
Perspective: In the OPTIC trial, amiodarone reduced ICD shocks by 73%. Instead of prophylactic RFCA of VT in all patients at the time of ICD implantation, one could make the case for treatment with amiodarone, with RFCA being reserved for patients who do not tolerate or who fail therapy with amiodarone. Fred Morady, M.D., F.A.C.C.
Title: Diabetic and Nondiabetic Patients With Left Main and/or 3-Vessel Coronary Artery Disease: Comparison of Outcomes With Cardiac Surgery and Paclitaxel-Eluting Stents
Topic: Cardiovascular Surgery
Date Posted: 1/15/2010
Author(s): Banning AP, Westaby S, Morice MC, et al.
Citation: J Am Coll Cardiol 2010;Jan 13:[Epub ahead of print].
Clinical Trial: No
Study Question: What is the impact of diabetes on outcome of patients with complex three-vessel or left main coronary artery disease who are treated with coronary artery bypass grafting (CABG) or paclitaxel-eluting stents (PES)?
Methods: The authors reported the outcome of diabetic patients enrolled in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) study. This study randomized 1,800 patients (452 with diabetes) to receive PES or CABG.
Results: Major adverse cardiac and cerebrovascular event rate at 1 year was higher among diabetic patients treated with PES compared with CABG (15.1 % vs. 11.8% ). There was no difference in the death/stroke/myocardial infarction rate with either revascularization strategy for nondiabetic patients (6.8% CABG vs. 6.8% PES, p = 0.97) or for diabetic patients (10.3% CABG vs. 10.1% PES, p = 0.96). Diabetic patients were at an increased risk of death after both CABG and PES. Mortality was higher after PES use (4.1% vs. 13.5%, p = 0.04) for diabetic patients with highly complex lesions (defined as a SYNTAX score ≥33). Compared with CABG, treatment with PES resulted in higher repeat revascularization for both nondiabetic patients (5.7% vs. 11.1%, p < 0.001) and diabetic patients (6.4% vs. 20.3%, p < 0.001).
Conclusions: Diabetes is associated with worse outcome among patients undergoing PES-based revascularization for complex coronary artery disease.
Perspective: Diabetes is associated with a greater prevalence of coronary artery disease and diabetic patients have a worse outcome after coronary revascularization compared with nondiabetics. The pre-eminence of CABG over PCI for revascularization of diabetics in the angioplasty and bare-metal stent era was based on higher rates of target vessel revascularization with PCI. The results of this and other studies (i.e., CARDia) suggest that drug-eluting stents have not been able to completely bridge this gap, and CABG remains the revascularization strategy for diabetic patients with multivessel coronary artery disease. Hitinder S. Gurm, M.B.B.S., F.A.C.C.
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