Ablation of VT in LVAD patients is feasible and can result in a markedly decreased VT burden with a reduction of ICD shocks. The subsequent discontinuation of intravenous antiarrhythmic medications may facilitate hospital discharge.

Aldosterone antagonists represented by nonselective spironolactone and mineralocorticoid-selective eplerenone are approved for treatment of symptomatic heart failure with reduced systolic function. Their cardioprotective, antifibrotic, and antiarrhythmic effects have been proven in animal experiments, and their effects on morbidity and mortality have been demonstrated in randomized clinical trials. Yet, they remain the most underutilized of all classes of medications for heart failure, primarily because of fear of hyperkalemia. Thorough patient screening and selection is the key for minimizing risks and optimizing benefits from these drugs. Ongoing trials will demonstrate whether the indication for aldosterone antagonists can be expanded to less severe heart failure or patients with preserved systolic function.

INTRODUCTION: In cardiac resynchronization therapy (CRT), our group has previously reported on positive clinical response and reverse remodeling using a novel robotically assisted left ventricular (LV) epicardial lead placement approach for pts with primary lead implant failure. In addition, CRT via transvenous approach is associated with an approximate 20% mortality rate at 18 mos. Long term mortality via robotic placement is unknown. METHODS: We evaluated 71 pts (70 ± 11 yrs, 48 [68%] male) who underwent robotic LV lead placement after failed transvenous LV lead placement. Leads were placed based on Tissue Doppler Imaging to localize the site of latest mechanical activation. The Social Security Death Index was queried to identify mortality. RESULTS: All pts had successful lead placement and were discharged in stable condition. During a follow-up (f/u) of 27 ± 16 mos, there were 18 deaths (25%) after 17.3 ± 14.5 mos (range 1.3 – 50.2 mos) (Figure ). These pts were older (77 ± 6 v. 68 ± 11 yrs; p < 0.001), with a lower EF (13 ± 7% v. 18 ± 9%; p < 0.05) and carried a greater symptom burden by NYHA class (3.6 ± 0.5 v. 3.1 ± 0.5; p = 0.02) when compared to those alive. There was no difference in pts with respect to HF duration, cardiomyopathy etiology or atrial fibrillation prevalence. A significant improvement in symptoms by NYHA class (3.1 ± 0.5 to 2.3 ± 0.7; p < 0.001) was seen at 8 ± 3 mos. CONCLUSION: Pts undergoing robotic LV lead implant show symptomatic improvement, and have a similar mortality rate to transvenous placement during f/u. Those at greatest risk for death include older pts with a very low EF; risk/benefit for these pts should be carefully considered before undergoing implant.