Management of ventricular arrhythmias in heart failure: Current perspectives

Abstract

Congestive heart failure (HF) is a progressive affliction defined as the inability of the heart to sufficiently maintain blood flow. Ventricular arrhythmias (VAs) are common in patients with HF, and conversely, advanced HF promotes the risk of VAs. Management of VA in HF requires a systematic, multimodality approach that comprises optimization of medical therapy and use of implantable cardioverter-defibrillator and/or device combined with cardiac resynchronization therapy. Catheter ablation is one of the most important strategies with the potential to abolish or decrease the number of recurrences of VA in this population. It can be a curative strategy in arrhythmia-induced cardiomyopathy and may even save lives in cases of an electrical storm. Additionally, modulation of the autonomic nervous system and stereotactic radiotherapy have been introduced as novel methods to control refractory VAs. In patients with end-stage HF and refractory VAs, an institution of the mechanical circulatory support device and cardiac transplant may be considered. This review aims to provide an overview of current evidence regarding management strategies of VAs in HF with an emphasis on interventional treatment.

Antiarrhythmic Treatment in Heart Failure

“…For primary prevention of SCD, several RCTs [ 71 – 74 ] support ICD therapy in HF patients with LVEF ≤ 35% by reporting a significant mortality reduction in this patient cohort. As the evidence is most robust in patients with ischemic etiology of HF, the current ESC guideline on VA and prevention of SCD gives a strong class I recommendation for symptomatic HFrEF patients with NYHA functional class II–III and LVEF ≤ 35% [ 66 , 75 ]. Mainly due to the more recent DANISH trial [ 76 ] that raised questions on the benefit of ICD therapy in patients with NICM as it failed to show a reduction in the primary endpoint of all-cause death by ICD therapy compared to standard care, the current ESC guideline gives a class IIa recommendation for this patient group.…”

“…As cardiomyopathy may be reversed by the elimination of PVCs, it is important to recognize this entity. However, despite elimination of PVCs, in some patients, LVEF does not return to normal, which may be caused by a preexisting (yet unknown) left ventricular dysfunction [ 75 ]. Thus, the diagnosis of PVC-induced cardiomyopathy can only be confirmed after improvement or normalization of LVEF following elimination of PVCs.…”

Basic Research Approaches to Evaluate Cardiac Arrhythmia in Heart Failure and Beyond

“…MEAs have been used to ascertain the effectiveness of anti-arrhythmic therapies. For example, a study by Kim et al (2022) used MEAs to evaluate the potential use of cardiac radioablation in the treatment of refractory ventricular arrhythmias, commonly seen in patients with heart failure (Peichl et al, 2021). The group monitored the electrical activity of iPSC-CM following irradiation, to further understand the electrophysiological response of the cells to the treatment.…”

The first case series analysis on efficacy of esmolol injection for in-hospital cardiac arrest patients with refractory shockable rhythms in China

“…Among our cases, more than 70% of the etiologies could be attributed to ACS and cardiac ion channel disease. A potential explanation is that shock-resistant rhythms occur most often in individuals with coronary artery disease and inherited arrhythmic syndromes (Polentini et al, 2006;Peichl et al, 2021). Of the four cardiac insufficiency cases, two (50%) failed to achieve sustained ROSC and the other two did not survive to discharge, suggesting that end-stage heart failure is associated with poorer clinical outcomes and may not be a reasonable indication for beta-blocker use (Park et al, 2022).…”