Device Therapy and Arrhythmia Management in Left Ventricular Assist Device Recipients: A Scientific Statement From the American Heart Association

Abstract

Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure with reduced ejection fraction. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common, predispose these patients to additional risk, and complicate patient management. However, there is no consensus on best practices for the medical management of these arrhythmias or on the optimal timing for procedural interventions in patients with refractory arrhythmias. Although the vast majority of these patients have preexisting cardiovascular implantable electronic devices or cardiac resynchronization therapy, given the natural history of heart failure, it is common practice to maintain cardiovascular implantable electronic device detection and therapies after LVAD implantation. Available data, however, are conflicting on the efficacy of and optimal device programming after LVAD implantation. Therefore, the primary objective of this scientific statement is to review the available evidence and to provide guidance on the management of atrial and ventricular arrhythmias in this unique patient population, as well as procedural interventions and cardiovascular implantable electronic device and cardiac resynchronization therapy programming strategies, on the basis of a comprehensive literature review by electrophysiologists, heart failure cardiologists, cardiac surgeons, and cardiovascular nurse specialists with expertise in managing these patients. The structure and design of commercially available LVADs are briefly reviewed, as well as clinical indications for device implantation. The relevant physiological effects of long-term exposure to continuous-flow circulatory support are highlighted, as well as the mechanisms and clinical significance of arrhythmias in the setting of LVAD support.

Ventricular arrhythmias following continuous‐flow left ventricular assist device implantation: A systematic review

“…A recent statement from the AHA in which a review of the literature was performed found the short-term success of VA ablation in a predominantly CF-LVAD cohort ranging from 77% to 86%, and variable VA recurrence at follow-up, ranging from 15% to 85%. 38 Moss et al reported an increased incidence of pump thrombosis following ablation in CF-LVAD patients, especially when ablation was performed adjacent to the inflow cannula. 14 However, larger prospective trials are needed to draw any conclusions about the risk of pump thrombosis and other complications associated with ablation in patients with CF-LVADs.…”

Continuous‐flow left ventricular assist devices: Management in the emergency department

“…Arrhythmias are common in patients with LVADs. The mechanisms behind arrhythmias in this patient populations are complex, however, they pertain to abnormal myocardium before LVAD implantation as well as ventricular remodeling therafter 26 . As it has been established that implantable cardioverter‐defibrillators (ICDs) improve survival in patients with both ischemic (and potentially non‐ischemic) cardiomyopathy, most patients who are considered for LVAD candidacy already have an ICD 27,28 .…”

“…As it has been established that implantable cardioverter‐defibrillators (ICDs) improve survival in patients with both ischemic (and potentially non‐ischemic) cardiomyopathy, most patients who are considered for LVAD candidacy already have an ICD 27,28 . The frequency of ventricular arrhythmias decrease as the patient becomes further removed from their LVAD implantation 26 …”

“…Though less “emergent” than a typical cardiac arrest, it is important to correct malignant arrhythmias to prevent RV failure. Though typical treatment of ventricular arrhythmias with medications in patients with LVADs is seldom successful, standard medications such as amiodarone, lidocaine, and procainamide may be used 26,30 . Treatment of the etiology of the ventricular arrhythmia (such as electrolyte abnormalities or a suction event) may lead to its resolution.…”

Noninvasive electrocardiographic mapping of ventricular tachycardia in a patient with a left ventricular assist device

“… 1 The burden of ventricular arrhythmias is high in these patients, with observational studies suggesting that as many as 20%–50% of patients experience ventricular arrhythmias after LVAD implantation. 2 , 3 Mechanisms of arrhythmogenesis include physical contact between the inflow cannula and myocardium, myocardial scar, and electrolyte disturbances. Ventricular tachycardia (VT) can be difficult to manage medically, and catheter ablation is often necessary.…”