John, with regard to the external validity question, is it more a question of interventional cardiologists who do a fair number of these procedures or who have had the proper training to do them? Even within the interventional cardiology community, there are those with more or less skills at certain procedures. What would you say is a good indicator or of an interventrial cardiologist’s competence to do such a VTY ablation procedure?
Excellent, John! Two important points to emphasize on the back of this well-done study: 1) your statement “VANISH 2 allows us to sit down with patients and discuss the results.” (it should be a collaborative decision) and 2) in order to offer ablation, the clinician must have strong confidence in the expertise of the ablation team.
This study assumes an ICD is a good idea. The stats don’t show much improvement in lifespan from these devices. And the scarring could result in an iatrogenic result that would be avoided if the patient had not had the ICD in the first place.
Agree with post-script. Whether a study is “positive” or not has little reflection on its quality. Good “Negative” studies can be more informative than lousy “positive” ones.
In this case, we can tell pts with ischemic CM, ICD, and VT, that ablation will reduce subsequent slow VT better than meds, but that’s about the extent of benefit. Patients can then weigh that vs upfront procedural risk, and potential risk of medication side effects. That’s a highly informative result.
When a procedural study does not have sham control, objective outcomes like VT is what we want to see….rather than subjective things like “oh some doc decided to admit you”.
John, with regard to the external validity question, is it more a question of interventional cardiologists who do a fair number of these procedures or who have had the proper training to do them? Even within the interventional cardiology community, there are those with more or less skills at certain procedures. What would you say is a good indicator or of an interventrial cardiologist’s competence to do such a VTY ablation procedure?
We must be careful of composite end points.
Because as pointed out here, the only differentiation between catheter ablation and meds is “reduction of subsequent slow rate VT”. And that is it.
i never trust composite endpoints. they're the researcher scoundrel's last refuge.
Probably a useful study in that it shows that there is no real difference between medication and ablation for outcomes that really matter.
Excellent, John! Two important points to emphasize on the back of this well-done study: 1) your statement “VANISH 2 allows us to sit down with patients and discuss the results.” (it should be a collaborative decision) and 2) in order to offer ablation, the clinician must have strong confidence in the expertise of the ablation team.
This study assumes an ICD is a good idea. The stats don’t show much improvement in lifespan from these devices. And the scarring could result in an iatrogenic result that would be avoided if the patient had not had the ICD in the first place.
Agree with post-script. Whether a study is “positive” or not has little reflection on its quality. Good “Negative” studies can be more informative than lousy “positive” ones.
In this case, we can tell pts with ischemic CM, ICD, and VT, that ablation will reduce subsequent slow VT better than meds, but that’s about the extent of benefit. Patients can then weigh that vs upfront procedural risk, and potential risk of medication side effects. That’s a highly informative result.
When a procedural study does not have sham control, objective outcomes like VT is what we want to see….rather than subjective things like “oh some doc decided to admit you”.
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Keep it simple. Excellent comment on excellent study.