Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
Department of Medicine, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada.
Europace. 2022 Jul 15;24(6):948-958. doi: 10.1093/europace/euab298.
Complexity of the ventricular tachycardia (VT) substrate and the size and thickness of infarction area border zones differ based on location of myocardial infarctions (MIs). These differences may translate into heterogeneity in the effectiveness of treatments. This study aims to examine the influence of infarct location on the effectiveness of VT ablation in comparison with escalated pharmacological therapy in patients with prior MI and antiarrhythmic drug (AAD)-refractory VT.
VANISH trial participants were categorized based on the presence or absence of an inferior MI scar. Inverse probability of treatment weighted Cox models were calculated for each subgroup. Of 259 randomized patients (median age 69.8 years, 7.0% women), 135 had an inferior MI and 124 had a non-inferior MI. Among patients with an inferior MI, no statistically significant difference in the composite primary outcome of all-cause mortality, appropriate implantable cardioverter-defibrillator (ICD) shock, and VT storm was detected between treatment arms [adjusted hazard ratio (aHR) 0.80, 95% confidence interval (CI) 0.51-1.20]. In contrast, patients with non-inferior MIs had a statistically significant reduction in the incidence of the primary outcome with ablation (aHR 0.48, 95% CI 0.27-0.86). In a sensitivity analysis of anterior MI patients (n = 83), a trend towards a reduction in the primary outcome with ablation was detected (aHR 0.50, 95% CI 0.23-1.09).
The effectiveness of VT ablation versus escalated AADs varies based on the location of the MI. Patients with MI scars located only in non-inferior regions of the ventricles derive greater benefit from VT ablation in comparison to escalation of AADs in reducing VT-related events.
根据心肌梗死（MI）的位置，室性心动过速（VT）基质的复杂性以及梗塞区域边界带的大小和厚度存在差异。这些差异可能会转化为治疗效果的异质性。本研究旨在检查梗塞部位对 VT 消融有效性的影响，并与先前 MI 和抗心律失常药物（AAD）难治性 VT 患者的升级药物治疗进行比较。
根据是否存在下壁 MI 瘢痕，将 VANISH 试验参与者进行分类。为每个亚组计算了逆概率治疗加权 Cox 模型。在 259 名随机患者（中位年龄 69.8 岁，7.0％为女性）中，135 例患有下壁 MI，124 例患有非下壁 MI。在下壁 MI 患者中，治疗组之间未发现全因死亡率，适当的植入式心脏复律除颤器（ICD）电击和 VT 风暴的复合主要结局有统计学上的显著差异[调整后的危险比（aHR）0.80，95％置信区间（CI）0.51-1.20]。相比之下，非下壁 MI 患者的消融术主要结局发生率明显降低（aHR 0.48，95％CI 0.27-0.86）。在前壁 MI 患者（n = 83）的敏感性分析中，检测到消融术降低主要结局的趋势（aHR 0.50，95％CI 0.23-1.09）。
VT 消融与升级 AAD 的有效性取决于 MI 的位置。与升级 AAD 相比，仅在心室非下壁区域存在 MI 瘢痕的患者，通过 VT 消融在减少 VT 相关事件方面获得更大的益处。
