The central question in recurrent ventricular tachycardia (VT) — whether to escalate drugs or ablate — has increasingly been answered in favor of catheter ablation. The VANISH2 trial compared catheter ablation with antiarrhythmic drug therapy (sotalol or amiodarone) as first-line treatment in patients with ischemic cardiomyopathy, significant VT, and an ICD: ablation reduced the composite of death, VT storm, appropriate ICD shock, or sustained VT requiring intervention (50.7% vs 60.6%), with fewer serious drug-related adverse events, though without a mortality difference. This builds on the earlier VANISH trial, in which ablation bettered drug escalation in patients with recurrent VT despite antiarrhythmics. Together they support moving catheter ablation earlier in the treatment algorithm. Emerging techniques — advanced substrate mapping, pulsed field ablation, bipolar and ultra-low-temperature cryoablation, and non-invasive stereotactic body radiotherapy (cardiac radioablation) for refractory cases — aim to improve lesion durability and reach otherwise inaccessible substrate.
Further reading: VANISH2 (Sapp et al., NEJM 2024); VANISH (Sapp et al., NEJM 2016); reviews of emerging VT ablation and stereotactic arrhythmia radioablation.