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(Circulation. 2007;116:1196-1203.)
© 2007 American Heart Association, Inc.

Controversies in Cardiovascular Medicine

Do patients with hemodynamically tolerated ventricular tachycardia require implantable cardioverter-defibrillators?

Response to Callans

Jesús Almendral, MD, PhD; Mark E. Josephson, MD

Although conventional wisdom might be against the use of implantable cardioverter-defibrillators (ICDs) for well-tolerated ventricular tachycardia (VT), the reverse (ie, implantation of ICDs) is intuitively more likely. The logic would be as follows: If we are implanting ICDs for primary prevention because patients are at risk of malignant ventricular arrhythmias, how could we not implant in patients who have already had a sustained VT (ie, the paradigm of a malignant arrhythmia)? Such a dilemma needs the discourse of scientific information that demonstrates that tolerated VT, adequately treated, is truly a malignant arrhythmia. Despite Dr Callans’ convincing discussion of secondary-prevention ICD trials, these trials do not help scientifically simply because patients with tolerated VT were explicitly excluded from them. The most important information derives from observational studies on catheter ablation, including almost 800 patients altogether. It is claimed that ablation does not "appear sufficiently protective" on the basis of a high rate of recurrent VT and total mortality. However, recurrent tolerated VT is overestimated by the ICD and is not a catastrophic event; it allows further therapy. Total mortality is high, but sudden death is low (2.5% after procedures considered successful). One of the series quoted as having high mortality (that of Calkins et al) is the series with the highest ICD implantation rate (79% had ICDs), suggesting that most deaths were nonarrhythmic and/or that the ICD contributed to the outcome. Thus, catheter ablation series are consistent with observational series from the 1980s and perhaps with the Antiarrhythmics Versus Implantable Defibrillator Registry, pointing toward a high total mortality but a low sudden death risk if the VT substrate can be substantially modified with catheter ablation or surgery. Why should we add the risks and complications of ICDs to all of these patients?

	Footnotes

 
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Callans, D. J. Search for Related Content PubMed PubMed Citation Articles by Callans, D. J. Related Collections Electrophysiology Ablation/ICD/surgery Arrhythmias, clinical electrophysiology, drugs