Is ablation better than antiarrhythmic drugs for ventricular tachycardia?

A substudy of the VANISH2 trial has found catheter ablation to be superior to sotalol in reducing ventricular tachycardia (VT) and VT-related events in sotalol-eligible patients. In those with more severe heart disease or VT storm, ablation demonstrates similar efficacy to amiodarone.

However, “amiodarone use is associated with relatively higher risks of potential side-effects, requiring careful patient evaluation, including comorbidity burden, anticipated duration of treatment, and patients’ values and preferences in light of risks and benefits of catheter ablation and antiarrhythmic drugs (AAD),” the investigators said. [J Am Acad Cardiol 2026;87:157-168]

A total of 416 patients were included, of whom 199 were randomly allocated to the sotalol arm and 217 to the amiodarone arm. The median follow-up duration was 4.3 years.

In the sotalol stratum, the primary endpoint of a composite of death, appropriate implantable cardioverter-defibrillator shock, VT storm, or treated sustained VT below the detection limit of the implantable cardioverter-defibrillator >14-days postrandomization occurred in 62 of 104 (59 percent) patients assigned to sotalol and in 44 of 95 (46 percent) patients assigned to catheter ablation (hazard ratio [HR], 0.64, 95 percent confidence interval [CI], 0.43‒0.94; p=0.02).

In the amiodarone stratum, the primary endpoint occurred in 67 of 109 (61 percent) patients assigned to AAD and in 59 of 109 (55 percent) who underwent ablation (HR, 0.86, 95 percent CI, 0.61‒1.22; p=NS).

Sustained VT below detection, in the sotalol stratum, occurred in two of 95 (2.1 percent) patients assigned to ablation and 18 of 104 (17.3 percent) assigned to sotalol (HR, 0.12, 95 percent CI, 0.03‒0.5; p=0.004) and, in the amiodarone stratum, in seven of 108 (96.5 percent) who underwent ablation and 17 of 109 (15.6 percent) who received amiodarone (HR, 0.41, 95 percent CI, 0.17‒0.99; p=0.048).

Adverse effects

However, among patients in the amiodarone arm, those assigned to drug therapy showed a threefold rise in noncardiac death (5.6 percent vs 16.5 percent), a twofold surge in respiratory failure (4.6 percent vs 11.0 percent), a 50-percent elevation in heart failure hospitalization (19.4 percent vs 31.2 percent), a 65-percent increase in sepsis (5.6 percent vs 9.2 percent), a threefold escalation in pneumonia cases (3.7 percent vs 11.9 percent), and a 4.6-percent incidence of pulmonary fibrosis or infiltrate relative to participants assigned to ablation.

“Although long-term use of amiodarone is associated with significant side effects, short-term administration carries a comparatively lower risk of adverse events,” the investigators said.

“Clinical decision-making should thus include a weighing of the importance of VT suppression against risks of therapy and should also balance the safety and efficacy of AAD administration vs catheter ablation, while incorporating individual patient preferences,” they added.

This substudy included patients who met the following criteria: estimated glomerular filtration rate ≥30 mL/min, NYHA functional class I-II, left ventricular ejection fraction ≥20 percent, qualifying arrhythmia was not VT storm, and no history of torsades de pointes or QT interval prolongation. All other patients were eligible to be randomized to either amiodarone or ablation.

Apart from the composite outcome mentioned above, other outcomes assessed included safety and the individual components of the primary endpoint. The investigators then compared all outcomes for catheter ablation with those for sotalol and to amiodarone separately.