Early catheter ablation as first-line therapy for ventricular tachycardia due to structural heart disease: A systematic review and meta-analysis.

BACKGROUND: Ventricular tachycardia (VT) poses a significant risk in patients with both ischemic and nonischemic cardiomyopathy. Implantable cardioverter defibrillators (ICDs) are placed to prevent sudden cardiac death, but ICD shocks can be painful and are known to have a negative effect on quality of life and survival. Currently, catheter ablation (CA) is usually used when anti-arrhythmic drugs fail to suppress VT, but its efficacy as a first-line treatment is uncertain. Therefore, a systematic review and meta-analysis were done to compare CA with standard medical therapy and/or ICD as first-line therapy for VT due to structural heart disease. METHODS: We included only randomized controlled trials comparing early CA with medical therapy and ICD implantation or ICD implantation alone in adults with ischemic or nonischemic cardiomyopathy. We searched various databases, including PubMed, Embase, MEDLINE, Cochrane Library, Google Scholar, Elsevier, clinicaltrials.gov, and previously published meta-analyses, for relevant studies from the date of inception till the completion of the literature search process. The risk of bias was assessed through the ROB 2.0 tool. The Primary outcome was defined as a composite of VT recurrence, appropriate ICD-shock, cardiovascular hospitalization, severe treatment-related complications, and death. A random effects meta-analysis was performed, and the GRADE tool was used to assess the certainty of the evidence. RESULTS: Eight randomized controlled trials, including 1333 patients, were analyzed. CA as first-line therapy significantly reduced the risk of the composite primary outcome - VT recurrence, appropriate ICD shocks, cardiovascular hospitalization, severe treatment-related complications, and death - compared to standard therapy (HR 0.66, 95% confidence interval: 0.55-0.80; P < .0001). Subgroup analysis showed greater benefit in patients with ischemic cardiomyopathy (HR 0.69), while results in mixed cardiomyopathy populations were inconclusive due to small sample size. CA also lowered mortality risk (HR 0.88), though this was not statistically significant. Overall heterogeneity was low (I2 = 19%), and the certainty of evidence was rated high. CONCLUSION: In patients with structural heart disease and VT, an initial strategy of CA as first-line therapy was found to be associated with better clinical outcomes.