CONTINUATION OF ANTIARRHYTHMIC DRUGS, OR ARRHYTHMIA SURGERY AFTER MULTIPLE-DRUG FAILURES - A RANDOMIZED TRIAL IN THE TREATMENT OF POSTINFARCTION VENTRICULAR-TACHYCARDIA

Background In patients with postinfarction sustained ventricular tachy cardia showing one or more antiarrhythmic drug failures, the question is how long to proceed with new drug trials before deciding to perform map-guided arrhythmia surgery. Although the techniques of this surger y developed rapidly in the early 1980s, this therapy may be offset by damage to residual left ventricular function. However, surgery has bee n shown to be very effective in selected groups of patients. Methods A randomized study was carried out in patients with postinfarction vent ricular tachycardia and eligible for arrhythmia surgery based on resid ual left ventricular function. Therapy failure was defined by the occu rrence of the following events: spontaneous recurrence of ventricular tachycardia or ventricular fibrillation, sudden cardiac death, inducib ility of sustained ventricular tachycardia or ventricular fibrillation with programmed stimulation of the heart, symptomatic non-sustained v entricular tachycardia requiring therapy or side-effects of antiarrhyt hmic drugs requiring withdrawal. In the drug limb, failure of the firs t antiarrhythmic drug was accepted but failure of a second and differe nt drug was regarded as true therapy failure. Results After randomizat ion, antiarrhythmic drug therapy was administered in 33 patients, and 30 patients underwent surgery. Neither group differed in baseline char acteristics, and the mean number of drug failures before randomization was 2.7. The Kaplan-Meier therapeutic failure of antiarrhythmic drugs was 39 +/- 11%, 42 +/- 11% and 51 +/- 18% at 0.5-, 1- and 4-year foll ow-up, respectively, whereas the therapeutic failure of cardiac surger y was 37 +/- 11%, 37 +/- 11% and 50 +/- 20% at 0.5, 1 and 4 years, res pectively, showing no statistical difference. The 1- and 4-year Kaplan -Meier survival of the antiarrhythmic drug-treated group was 91 +/- 6% and 78 +/- 15%, respectively, and of the surgical group 92 +/- 6% and 59 +/- 20%, respectively, and did not differ between either group. Ho wever, the relative risk for total cardiac death was higher in the sur gical limb than in the drug limb (relative risk 2.2, CI 0.68-7.48). Co nclusion This study demonstrated no difference between the therapeutic result of continuation of two different antiarrhythmic drugs and that of arrhythmia surgery. Despite the small number of patients studied, it is recommended that drug therapy should continue as long as this re gimen is tolerated by the patient. When true drug refractoriness or si de-effects of drugs arise, arrhythmia surgery offers a valuable altern ative. However, when additional reasons for cardiac surgery exist, arr hythmia surgery should be undertaken earlier and may become the first choice of treatment of postinfarction ventricular tachycardia.