5 #AHA24 ScientificSessions.org Redefining Arrhythmia Treatment Saturday’s Late-Breaking Science session “Redefining Arrhythmia Treatment: Pushing Boundaries” found that: • Catheter ablation tops antiarrhythmic drug therapy to block VT in ischemic cardiomyopathy. • OPTION showed left atrial appendage device beats oral anticoagulation for bleeding after AF ablation. • No cognitive impairment or stroke benefit from oral anticoagulation seen in BRAIN-AF. The first large head-to-head trial of catheter ablation versus antiarrhythmic drug therapy to suppress ventricular tachycardia (VT) following myocardial infarction (MI) suggested ablation is the preferred first-line therapy for patients who have persistent VT with an implantable cardioverter-defibrillator (ICD). The VANISH2 trial showed a 25% benefit for ablation (HR 0.75, 95% CI 0.580.97, p=0.03) without major differences in safety compared to antiarrhythmic drug therapy. Patients were followed for a median of 4.3 years. Sapp “In terms of serious adverse events, there was no statistically significant difference, although the trend was toward better survival following catheter ablation” said John Sapp, MD, professor of cardiology at Dalhousie University in Halifax, Canada. “We observed the anticipated drug side effects and procedural complications.” Cardiac arrhythmia that stems from electrical dysfunction across ischemic scars is one of the most common causes of sudden death in individuals who have had one or more prior MI’s, Sapp said. VT is the most common arrhythmia leading to sudden death in the days to weeks and years following MI. The VANISH1 trial established the superiority of catheter ablation versus escalation of drug therapy in patients with VT despite antiarrhythmic drug therapy but did not address first-line treatment. VANISH2 randomized 416 patients in North America and Europe with prior MI and clinically significant VT, defined as VT storm, appropriate ICD shock, recurrent anti-tachycardia pacing, or sustained VT presenting for emergent treatment. Patients received either catheter ablation (203 patients) or drug therapy (213 patients) with sotalol or amiodarone as initial therapy. Ablation was performed within 14 days of randomization. The primary endpoint was a composite of death or, ≥ 14 days after treatment, VT storm, appropriate ICD shock or sustained VT that presented for emergent treatment emergently. The primary endpoint was seen in 50.7% of patients who received ablation and 60.6% of those who received drug treatment, a 9.9% absolute reduction and 25% relative reduction for ablation. Among patients randomized to ablation, death was observed in 1.0% of patients, nonfatal stroke in 1.0%, cardiac perforation in 0.5% and vascular injury in 1.9%. Among patients randomized to drug treatment, one died due to pulmonary toxicity and 21.6% experienced nonfatal drug-related adverse events. While VANISH2 clearly demonstrated a benefit for ablation versus antiarrhythmic drug therapy as first-line treatment for ischemic cardiomyopathy, the trial did not address other, nonischemic causes of VT. Sapp noted that VT resulting from cardiac scarring other than MI can be more difficult to treat with ablation than VT associated with MI scarring. “We still need to understand how best to treat patients with VT who have nonischemic cardiomyopathy,” Sapp said. “The outcomes for ablation may be different in that population and the relative benefits and risks could therefore be different as well.” VANISH2 was published simultaneously in the New England Journal of Medicine. Left atrial appendage closure beats oral anticoagulation for bleeding after catheter ablation The first direct comparison between oral anticoagulation and left atrial appendage closure (LAAC) using the WATCHMAN implant after catheter ablation for atrial fibrillation (AFib) found significantly less major or clinically relevant nonmajor bleeding, 8.5% for LAAC versus 18.1% for oral anticoagulation. The closure device was statistically non-inferior to oral anticoagulation for a composite endpoint of all-cause death, stroke or systemic embolism at 36 months (5.3% vs. 5.8%, respectively, p for noninferiority <0.0001) with a numerical trend for superiority. Wazni “This has the possibility of changing clinical practice,” said Oussama Wazni, MD, MBA, head of electrophysiology at the Cleveland Clinic. “I think people are going to want to close the left atrial appendage and not have to worry about anticoagulation, especially because the difference in bleeding rates was so high.” See ARRHYTHMIA, page 15 Streamlining the pathway to publish cardiovascular research The American Heart Association (AHA) is thrilled to announce a new collaboration between the New England Journal of Medicine (NEJM) and the AHA’s flagship journal Circulation. In January 2025, research authors will have the option to select a seamless transfer of their manuscript between NEJM and Circulation. This pilot program leverages the expertise of the journals’ worldclass editors and peer reviewers to streamline the publication of novel cardiovascular research. NEJM is the most widely read and cited general medicine journal in the world, and coupled with Circulation’s stature in cardiology this arrangement helps to expedite the submission process for authors, simplifying the publication pathway for high-impact cardiovascular articles. This collaboration aims to strengthen, diversify and improve the quality of research published in both journals, providing greater benefits to authors and readers. Together, the journals are set to amplify the sharing of innovative cardiovascular research, speed the publication of practicechanging science and address pressing health challenges, while underscoring each organization’s commitment to improving global health outcomes for the benefit of patients everywhere. Post-conference survey We want to hear from you! Don’t miss out on an opportunity to be randomly selected to receive complimentary registration to Scientific Sessions 2025.
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