Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion

David Žižek; Miha Mrak; Matevž Jan; Anja Zupan Mežnar; Maja Ivanovski; Tadej Žlahtič; Nina Kajdič; Bor Antolič; Luka Klemen; Rafael Skale; Jurij Avramovič Gregorič; Jernej Štublar; Andrej Pernat; Matjaž Šinkovec

doi:10.1093/europace/euae109

Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion

Europace. 2024 Apr 24:euae109. doi: 10.1093/europace/euae109. Online ahead of print.

Authors

David Žižek^{1

2}, Miha Mrak^{1

2}, Matevž Jan³, Anja Zupan Mežnar^{1

2}, Maja Ivanovski¹, Tadej Žlahtič¹, Nina Kajdič¹, Bor Antolič¹, Luka Klemen¹, Rafael Skale⁴, Jurij Avramovič Gregorič⁵, Jernej Štublar¹, Andrej Pernat¹, Matjaž Šinkovec^{1

2}

Affiliations

¹ Cardiology Department, University Medical Centre Ljubljana, Ljubljana, Slovenia.
² University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia.
³ Cardiovascular Surgery Department, University Medical Centre Ljubljana, Ljubljana, Slovenia.
⁴ Cardiology Division, General Hospital Celje, Celje, Slovenia.
⁵ Cardiology Division, General Hospital Izola, Izola, Slovenia.

PMID: 38657209
DOI: 10.1093/europace/euae109

Abstract

Background: Primary prevention patients with ischemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (IRA-CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence.

Aim: To evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation.

Methods: The PREVENTIVE VT study was a prospective, multicenter, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented VAs, and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality.

Results: Sixty patients were included in the study. During the mean follow-up of 44.7± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.12-0.94; P=0.037). Patients in the preventive ablation group also had fewer appropriate ICD therapies (P=0.039) and the electrical storms (Log rank: P=0.01). While preventive ablation also reduced cardiac hospitalizations (P=0.006), it had no significant impact on CV mortality (P=0.151).

Conclusions: Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

Keywords: catheter ablation; implantable cardioverter-defibrillator; ischaemic cardiomyopathy; ventricular arrhythmia.