Mechanical circulatory support in ventricular arrhythmias

Abstract

In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.

Entrapment of high-density grid mapping catheter in a percutaneous ventricular assist device pigtail during ventricular tachycardia ablation with percutaneous hemodynamic support

“…A number of studies have shown benefit in supporting patients at high risk for hemodynamic decompensation with MCS during VT ablation. 1 , 6 , 7 , 11 , 12 The Impella CP is frequently used given ease of placement from the femoral artery and up to 4.3 L/min of support. Other options for percutaneous support include the TandemHeart (Cardiac Assist, Inc, Pittsburg, PA), which is inserted through a 21F venous cannula placed transseptally in the left atrium with 17F arterial return cannula as well as VA ECMO.…”

“… 13 Although VA ECMO can provide complete circulatory support, it has a higher risk of vascular complications, it can increase LV afterload, thereby worsening LV function, and is resource intensive. 1 …”

“…Patients with incessant ventricular tachycardia (VT), sustained VT despite treatment with antiarrhythmic drugs, or shocks from implantable defibrillators are candidates for catheter ablation (CA). 1 , 2 , 3 Although ablation can be efficacious, mortality is higher in patients with structural heart disease owing to hemodynamic instability from anesthesia and arrhythmia induction. 1 , 3 , 4 The PAINESD risk score helps to identify patients at risk of acute hemodynamic decompensation, permitting selection of those likely to benefit from intraprocedural mechanical circulatory support (MCS).…”

“… 1 , 2 , 3 Although ablation can be efficacious, mortality is higher in patients with structural heart disease owing to hemodynamic instability from anesthesia and arrhythmia induction. 1 , 3 , 4 The PAINESD risk score helps to identify patients at risk of acute hemodynamic decompensation, permitting selection of those likely to benefit from intraprocedural mechanical circulatory support (MCS). 5 In patients at high risk, temporary MCS, including percutaneous left ventricular (LV) assist devices (pLVADs) and venoarterial extracorporeal membrane oxygenation (VA ECMO) facilitates CA while reducing end-organ hypoperfusion, hemodynamic collapse, and worsening heart failure.…”