Catheter ablation versus medical therapy for treatment of ventricular tachycardia associated with structural heart disease: Systematic review and meta-analysis of randomized controlled trials and comparison with observational studies
Catheter ablation versus medical therapy for treatment of ventricular tachycardia associated with structural heart disease: Systematic review and meta-analysis of randomized controlled trials and comparison with observational studies
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DOI：
10.1016/j.hrthm.2019.05.026
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发表时间：
2019-10-01
期刊：
影响因子：
5.5
通讯作者：
Kumar, Saurabh
中科院分区：
文献类型：
--
作者：
Anderson, Robert D.;Ariyarathna, Nilshan;Kumar, Saurabh
背景：导管消融（CA）是室性心动过速（VT）的一种既定治疗方式。目的：我们比较了所有之前进行的随机对照试验（rct）中CA治疗VT与药物治疗的临床结果，并将其与当代观察性研究进行了比较。方法：通过全面的数据库检索，截至2018年8月，确定了8项符合条件的研究，纳入了797名患者。结果在随机对照试验中，CA组与药物治疗组相比，在平均随访22个月时，VT复发率和电性VT风暴明显降低（相对危险度[RR] 0.78, 95%可信区间[CI] 0.64 ~ 0.95, P = 0.01；相对危险度[RR] 0.70, 95% CI 0.51 ~ 0.94, P = 0.02）。全因死亡率或心脏特异性死亡率无显著差异（RR 0.92, 95% CI 0.67-1.27, P = 0.62; RR 0.82, 95% CI 0.54-1.26, P = 0.37）。在4项观察性研究中，包括3065例患者，平均随访18.2个月，尽管电风暴发生率较高（33.2%对17%，P < 0.001），非缺血性底物患病率较高（46.4%对3.6%,P < 0.001），植入式icd发生率较低（68%对94.7%,P < 0.001），但与随机对照试验相比，VT复发率和死亡率显著降低（28.6%对39%，P < 0.001； 13.2%对18%，P = 0.01）。结论：RCT数据的荟萃分析显示，在VT复发和电性VT风暴方面，CA优于药物治疗，主要是梗死后、疤痕相关的VT，且死亡率没有降低。现实世界的观察性研究也表明，尽管病情较重，但室性室复发和死亡率显著降低，证明了RCT数据在现实世界中的可复制性和可翻译性。
BACKGROUND Catheter ablation (CA) is an established therapeutic modality for ventricular tachycardia (VT).OBJECTIVE We compared the clinical outcomes of CA for VT vs medicaltherapy from all previously performed randomized controlled trials (RCTs) and compared these to contemporary observational studies.METHODS A comprehensive database search through to August 2018 identified 8 eligible studies enrolling 797 patients.RESULTS In RCTs, VT recurrence and electrical VT storm were significantly reduced in the CA group vs medical therapy group (relative risk [RR] 0.78, 95% confidence interval [CI] 0.64-0.95, P = .01; RR 0.70, 95% CI 0.51-0.94, P = .02, respectively) at a mean follow-up of 22 months. All-cause or cardiac-specific mortality did not differ significantly (RR 0.92, 95% CI 0.67-1.27, P = .62; RR 0.82, 95% CI 0.54-1.26, P = .37, respectively). In 4 observational studies, including 3065 patients with a mean follow-up of 18.2 months, VT recurrence and mortality were significantly lower as compared to the RCTs (28.6% vs 39%, P < .001; 13.2% vs 18%, P = .01, respectively) despite greater incidence of electrical storm (33.2% vs 17%, P < .001), higher prevalence of nonischemic substrate (46.4% vs 3.6%, P < .001), and lower rate of implanted ICDs (68% vs 94.7%, P < .001).CONCLUSION Meta-analysis of RCT data shows that CA is superior to medical therapy for predominantly postinfarct, scar-related VT in terms of VT recurrence and electrical VT storm, with no reduction in mortality. Real-world observational studies also demonstrate significant reduction in VT recurrence and mortality, despite a sicker cohort, demonstrating replicability and translation of RCT data in the real world.