Ablation of Stable VTs Versus Substrate Ablation in Ischemic Cardiomyopathy the VISTA Randomized Multicenter Trial

Background Catheter ablation reduces ventricular tachycardia (VT) recurrence and implantable cardioverter defibrillator shocks in patients with VT and ischemic cardiomyopathy. The most effective catheter ablation technique is unknown. Objectives This study determined rates of VT recurrence in patients undergoing ablation limited to clinical VT along with mappable VTs ("clinical ablation") versus substrate-based ablation. Methods Subjects with ischemic cardiomyopathy and hemodynamically tolerated VT were randomized to clinical ablation (n = 60) versus substrate-based ablation that targeted all "abnormal" electrograms in the scar (n = 58). Primary endpoint was recurrence of VT. Secondary endpoints included periprocedural complications, 12-month mortality, and rehospitalizations. Results At 12-month follow-up, 9 (15.5%) and 29 (48.3%) patients had VT recurrence in substrate-based and clinical VT ablation groups, respectively (log-rank p < 0.001). More patients undergoing clinical VT ablation (58%) were on antiarrhythmic drugs after ablation versus substrate-based ablation (12%; p < 0.001). Seven (12%) patients with substrate ablation and 19 (32%) with clinical ablation required rehospitalization (p = 0.014). Overall 12-month mortality was 11.9%; 8.6% in substrate ablation and 15.0% in clinical ablation groups, respectively (log-rank p = 0.21). Combined incidence of rehospitalization and mortality was significantly lower with substrate ablation (p = 0.003). Periprocedural complications were similar in both groups (p = 0.61). Conclusions An extensive substrate-based ablation approach is superior to ablation targeting only clinical and stable VTs in patients with ischemic cardiomyopathy presenting with tolerated VT

Impact of Life-Style Change on the Arrhythmia Status in Patients With Long-Standing Persistent Atrial Fibrillation

Background: Aggressive life-style changes by reversing obesity reportedly cause significant decrease in arrhythmia burden and symptom severity, thereby reducing or eliminating the need for arrhythmia medications in AF patients. However, these observations were documented in populations comprised primarily of paroxysmal and persistent AF patients. This study investigated the impact of lifestyle changes on AF status and quality of life (QoL) in long-standing persistent (LSPAF) patients. Methods: Fifty-two LSPAF patients [age 64\ub110 years, 71% male, weight 256 (IQR 216 -342) lb.] were included in this prospective analysis. Subjects that volunteered to try weight-loss interventions undertook aggressive diet and exercise measures for 1 year while remaining on anti-arrhythmic drugs. They received Individualized diet menus prepared by experienced nutritionists to achieve targeted weight loss and were prescribed moderate-intensity exercise; 150 minutes/week of brisk walking (15 minutes a mile) or bicycling slower than 10 miles per hour. At the beginning and end of the intervention period, body weight was measured; arrhythmia status was evaluated by ECG, Holter and Atrial Fibrillation Symptom Severity (AFSS) survey and QoL was assessed by SF-36 survey. A scoring algorithm with two summary measures, PCS and MCS was prepared for QoL analysis. Results: After 1-year of intervention, significant reduction in body weight (median -54 (IQR -42 to -120) lb., p<0.001) was observed. Also, the PCS and MCS scores demonstrated substantial improvement with a change from baseline of 8.4\ub13 (p=0.013) and 12.8\ub18.2 (p <0.02) respectively. However, no such impact was observed on the AF symptoms. Two (3.8%) and 3(5.8%) patients were asymptomatic, 18(34.6%) and 15(28.8%) had mild, 28(53.8%) and 31(56.9%) had moderate, and 4(7.7%) and 3(5.8%) patients experienced severe symptoms, pre- and post-intervention respectively (p=0.85). Similarly, very little change in AF burden was observed at the end of the intervention. All patients underwent catheter ablation for AF, eventually. Conclusions: In LSPAF patients, aggressive life-style changes lead to considerable weight-loss and improvement in quality of life. However, substantial weight loss does not alter the AF status