Characteristics of Ventricular Tachycardia Ablation in Patients With Continuous Flow Left Ventricular Assist Devices

Abstract

Background-Left ventricular assist devices (LVADs) are increasingly used as a bridge to cardiac transplantation or as destination therapy. Patients with LVADs are at high risk for ventricular arrhythmias. This study describes ventricular arrhythmia characteristics and ablation in patients implanted with a Heart Mate II device. Methods and Results-All patients with a Heart Mate II device who underwent ventricular arrhythmia catheter ablation at 9 tertiary centers were included. Thirty-four patients (30 male, age 58±10 years) underwent 39 ablation procedures. The underlying cardiomyopathy pathogenesis was ischemic in 21 and nonischemic in 13 patients with a mean left ventricular ejection fraction of 17%±5% before LVAD implantation. One hundred and ten ventricular tachycardias (VTs; cycle lengths, 230-740 ms, arrhythmic storm n=28) and 2 ventricular fibrillation triggers were targeted (25 transseptal, 14 retrograde aortic approaches). Nine patients required VT ablation <1 month after LVAD implantation because of intractable VT. Only 10/110 (9%) of the targeted VTs were related to the Heart Mate II cannula. During follow-up, 7 patients were transplanted and 10 died. Of the remaining 17 patients, 13 were arrhythmia-free at 25±15 months. In 1 patient with VT recurrence, change of turbine speed from 9400 to 9000 rpm extinguished VT. Conclusions-Catheter ablation of VT among LVAD recipients is feasible and reasonably safe even soon after LVAD implantation. Intrinsic myocardial scar, rather than the apical cannula, seems to be the dominant substrate.

Effect of Ventricular Arrhythmia Ablation in Patients With Heart Mate II Left Ventricular Assist Devices: An Evaluation of Ablation Therapy

“…This may suggest that ablation should be considered after appropriate treatment of the underlying heart failure. In patients who develop arrhythmias following LVAD implantation, the authors hypothesize that the hemodynamic and electrophysiologic changes predispose these patients to an increase in event rate rather than overt worsening of the heart failure, consistent with prior studies . It should be noted that LVAD‐related events, including LV suction and atrial fibrillation, have a higher predisposition for VA likely not directly related to the underlying substrate.…”

“…showed that the prevalence of VA within 30 days of LVAD implantation was 20.2%, which did not improve after the first 30 days of implantation . The presence of VA confers a higher mortality rate, longer durations of hospitalization, and increased mortality . A study by Brenyo et al .…”

“…One of the downsides to LVAD therapy is the higher predisposition to ventricular arrhythmias (VAs). Exacerbation of underlying VA has been described in patients undergoing LVAD implantation . A study of 94 patients by Garan et al .…”

Cardiac Resynchronization Therapy and Clinical Outcomes in Continuous Flow Left Ventricular Assist Device Recipients

“…Multiple mechanisms contribute but delayed incidence of VAs is mostly secondary to pre‐existing substrate combined with a lack of favorable remodeling from the LVADs 23, 24. Sustained VAs are well tolerated by the LVAD‐supported LV, but prolonged duration of VAs can result in right ventricular dysfunction and right heart failure, which can contribute to worse outcomes in LVAD patients 25, 26.…”

Unanswered Questions in Contemporary Heart Failure

“…In 2016, while this study was being conducted, Sapp et al published the VANISH study which demonstrated the benefit of ablation over escalation of antiarrhythmic therapy in patients with ischemic cardiomyopathy (10). In addition, there has been some work examining the feasibility and utility of VT ablation in patients with VADs (11), but its role remains unclear.…”