Sustained monomorphic VT in ischemic cardiomyopathy — amiodarone vs catheter ablation, which is first-line?

1 Answer

This is a patient with ischemic cardiomyopathy (EF ~30%) and recurrent sustained monomorphic VT despite ICD and amiodarone, representing drug-refractory VT with recurrent ICD therapies. In this setting, catheter ablation is preferred over further antiarrhythmic escalation. Evidence from the VANISH trial demonstrated that, in patients with ischemic cardiomyopathy and recurrent VT on amiodarone (or sotalol), catheter ablation significantly reduced the composite of death, VT storm, or appropriate ICD shocks compared with escalation of antiarrhythmic therapy. Similarly, the SMASH-VT trial showed that substrate-based VT ablation reduced subsequent ICD therapies compared with ICD alone. Therefore, in a patient already on amiodarone with recurrent ICD shocks, escalation to higher doses or additional antiarrhythmics offers limited incremental benefit and higher toxicity, whereas VT ablation provides better arrhythmia control and reduces ICD shocks. Efficacy: Acute procedural success (non-inducibility of clinical VT) is achieved in ~70–85%, with significant reduction in VT burden and ICD shocks. However, recurrence can occur (≈30–50% over time), especially in advanced substrate disease. Risks: Include vascular complications, cardiac perforation/tamponade, stroke, worsening heart failure, and, rarely, procedure-related mortality (~1–3%). Epicardial access (if required) adds risk of pericardial bleeding or coronary injury. Conclusion: In ischemic cardiomyopathy with recurrent ICD shocks despite amiodarone, catheter ablation is the preferred next step, supported by VANISH, with the goal of reducing VT burden and ICD therapies while avoiding further drug toxicity.