Catheter Ablation vs Sotalol or Amiodarone for Ventricular Tachycardia
Key result
Catheter ablation cuts major events ~36% vs. sotalol, matching amiodarone with fewer adverse events.
- HR 0.64
- 95% CI 0.43-0.94
- P=0.02
- n=416
Why the study?
The comparative outcomes of catheter ablation versus antiarrhythmic drugs, stratified by drug eligibility, in patients with prior myocardial infarction and ventricular tachycardia were uncertain.
Does catheter ablation reduce a composite of death, appropriate ICD shock, VT storm, or treated sustained VT compared to sotalol or amiodarone in patients with prior myocardial infarction and ventricular tachycardia?
Key Points
- To compare clinical outcomes of catheter ablation versus antiarrhythmic drugs according to baseline drug eligibility strata (sotalol versus amiodarone) in patients with prior myocardial infarction and ventricular tachycardia.
- Prespecified substudy of the multicenter randomized VANISH2 trial (NCT02830360) evaluating 416 patients followed for a median of 4.3 years.
- Patients were stratified into sotalol-eligible (eGFR ≥30 mL/min, NYHA class I-II, LVEF ≥20%, qualifying arrhythmia not VT storm, and no QT prolongation; n=199) or amiodarone-eligible (all other patients; n=217) cohorts and randomly allocated to catheter ablation or drug therapy.
- The primary endpoint was a composite of death, appropriate implantable cardioverter-defibrillator shock, VT storm, or treated sustained VT below detection limit >14 days postrandomization.
- In the sotalol stratum, the primary composite endpoint occurred in 44 of 95 patients (46%) assigned to catheter ablation versus 62 of 104 (59%) assigned to sotalol (HR: 0.64; 95% CI: 0.43-0.94; P = 0.02).
- In the amiodarone stratum, the primary endpoint occurred in 59 of 108 patients (55%) assigned to ablation versus 67 of 109 (61%) assigned to amiodarone (HR: 0.86; 95% CI: 0.61-1.22; P = NS).
- Patients receiving amiodarone experienced higher adverse event rates than those undergoing ablation, including noncardiac death (16.5% vs 5.6%), respiratory failure (11.0% vs 4.6%), heart failure hospitalization (31.2% vs 19.4%), and pulmonary fibrosis or infiltrate (4.6% vs 0%).
Study Design
Type
RCT (n=416)
Randomization
Stratified by drug eligibility
Multicenter
Yes
Structured PICO
Does catheter ablation reduce a composite of death, appropriate ICD shock, VT storm, or treated sustained VT compared to sotalol or amiodarone in patients with prior myocardial infarction and ventricular tachycardia?
P
Population
416 patients with prior myocardial infarction and ventricular tachycardia, stratified by antiarrhythmic drug eligibility, followed for a median of 4.3 years.
I
Intervention
Catheter ablation
C
Comparator
Antiarrhythmic drugs (sotalol for sotalol-eligible stratum, amiodarone for amiodarone-eligible stratum)
O
Outcome
Composite of death, appropriate implantable cardioverter-defibrillator shock, VT storm, or treated sustained VT below the detection limit of the implantable cardioverter-defibrillator >14-days postrandomizationcomposite
Main Result
Hazard Ratio: 0.64 (95% CI 0.43–0.94)
Absolute Event Rate: 46% vs 59%
p-value: p=0.02
In patients with prior MI and VT, catheter ablation reduces the risk of death or recurrent ventricular arrhythmias compared to sotalol in sotalol-eligible patients, while exhibiting comparable efficacy but fewer adverse events than amiodarone in amiodarone-eligible patients.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“An initial strategy of catheter ablation resulted in a lower risk of the composite outcome, although both approaches were associated with adverse events and were found to have imperfect efficacy.”
SASana Al-KhatibCardiac electrophysiologist, Duke University
“The tradition has been to treat those patients with medications and really to introduce catheter ablation late in the game. And I've always questioned that.”
Implication
Ablation reduced primary events vs sotalol in eligible patients (HR 0.64); extends VANISH2 to guide stratified first-line therapy choice.
Abstract
BACKGROUND: In the VANISH2 multicenter randomized trial comparing catheter ablation to antiarrhythmic drugs (AADs) for patients with prior myocardial infarction and ventricular tachycardia (VT), randomization was stratified by drug eligibility based on clinical criteria. OBJECTIVES: The objective of this prespecified substudy was to compare the outcomes of catheter ablation vs AAD according to drug eligibility stratum. METHODS: Patients were considered eligible to be allocated to sotalol vs ablation if they met all the following criteria: estimated glomerular filtration rate ≥30 mL/min, NYHA functional class I-II, left ventricular ejection fraction ≥20%, qualifying arrhythmia was not VT storm, and no history of torsades de pointes or QT interval prolongation. All other patients were eligible to be randomly allocated to amiodarone vs ablation. The primary endpoint was a composite of death, appropriate implantable cardioverter-defibrillator shock, VT storm, or treated sustained VT below the detection limit of the implantable cardioverter-defibrillator >14-days postrandomization. Secondary endpoints included safety and the individual components of the primary endpoint. In this analysis, the primary and secondary outcomes for catheter ablation are compared with those for sotalol and to amiodarone separately. RESULTS: A total of 416 patients (199 in sotalol and 217 in amiodarone strata) were followed for a median of 4.3 years. In the sotalol stratum, a primary endpoint occurred in 44 of 95 patients (46%) assigned to catheter ablation and in 62 of 104 (59%) assigned to sotalol (HR: 0.64; 95% CI: 0.43-0.94; P = 0.02). In the amiodarone stratum, a primary endpoint occurred in 59 of 108 (55%) patients assigned to ablation and 67 of 109 (61%) assigned to AAD (HR: 0.86; 95% CI: 0.61-1.22; P = NS). In the sotalol stratum, sustained VT below detection occurred in 2 of 95 (2.1%) patients randomized to ablation and 18 of 104 (17.3%) assigned to sotalol (HR: 0.12; 95% CI: 0.03-0.5; P = 0.004). In the amiodarone stratum it occurred in 7 of 108 (6.5%) randomized to ablation and 17 of 109 (15.6%) assigned to amiodarone (HR: 0.41; 95% CI: 0.17-0.99; P = 0.048). In the amiodarone stratum, patients allocated to drug therapy had a 3-fold increase in noncardiac death (5.6% vs 16.5%), a 2-fold increase in respiratory failure (4.6% vs 11.0%), a 50% increase in heart failure hospitalization (19.4% vs 31.2%), a 65% increase in sepsis (5.6% vs 9.2%), a 3-fold increase in pneumonia (3.7% vs 11.9%), and 4.6% incidence of pulmonary fibrosis/infiltrate (vs 0%), when compared with patients allocated to ablation. CONCLUSIONS: In the sotalol-eligible patients, ablation led to lower risk of the primary composite endpoint. In the amiodarone-eligible group, efficacy outcomes were comparable between ablation and amiodarone. Adverse events were more marked among patients randomized to amiodarone (Antiarrhythmics or Ablation for Ventricular Tachycardia 2 [VANISH2]; NCT02830360).
Discussion
No takes yet. Share an insight, caveat, or question.
Cite This Study
Nery et al. (2025) conducted an RCT in Prior myocardial infarction and ventricular tachycardia (n=416). Catheter ablation vs. Sotalol or amiodarone was evaluated on Composite of death, appropriate implantable cardioverter-defibrillator shock, VT storm, or treated sustained VT below the detection limit of the ICD >14-days postrandomization (sotalol stratum) (HR 0.64, 95% CI 0.43-0.94, p=0.02). Catheter ablation reduced the primary composite endpoint compared to sotalol (HR 0.64; 95% CI 0.43-0.94; P=0.02), but had comparable efficacy to amiodarone with fewer adverse events.