The role of percutaneous left ventricular assist devices during ventricular tachycardia ablation

Abstract

Ventricular tachycardia (VT) is a common but serious arrhythmia that significantly adds to the morbidity and mortality of patients with structural heart disease. Percutaneous catheter ablation has evolved to be standard therapy to prevent recurrent implantable cardioverter defibrillator shocks from VT in patients on antiarrhythmia medications. Procedural outcomes in patients with structural heart disease are often limited by haemodynamically unstable VT. Although substrate- and pace-mapping techniques have become increasingly popular for VT ablation, these approaches can often times may not address inducible clinical and non-clinical VTs. Activation and entrainment mapping can help the operator target VT exit sites in a precise fashion minimizing the amount of radiofrequency ablation needed for a successful ablation. An evolving alternative strategy that allows induction and mapping of VT in the setting of severe cardiomyopathy and haemodynamic instability is through maintaining perfusion with a percutaneous ventricular assist device (pVAD). This review will discuss these pVAD technologies, distinguish technical applications of use, highlight the published clinical experience, provide a clinical approach for support device selection, and discuss use of these technologies with current mapping and navigational systems.

Ventricular Tachycardia Ablation in Severe Heart Failure

“…[4][5][6][7][8] In addition, use of percutaneous left ventricular assist devices (LVADs) during ablation, in selected cases, has helped to minimize hemodynamic compromise. 9,10 Not only has the need for repeated VT induction and activation mapping been minimized with contemporary approaches, but freedom from VT recurrence and outcomes have been improved. 8 We sought to assess the safety and efficacy of VT ablation in patients with NYHA IV HF and ventricular arrhythmias refractory to medical therapy among a contemporary group of patients included in the cohort established by the International VT Ablation Center Collaborative Group (IVTCC).…”

Percutaneous Left Ventricular Assist Devices in Ventricular Tachycardia Ablation

“…6 All the pLVADs were placed in the electrophysiology laboratory by the operating electrophysiology or an interventional cardiologist using standard techniques as described elsewhere, before the placement of diagnostic catheters. 4,9,10 See Data Supplement and Figures 1 to 3 for implantation details. Low left ventricular ejection faction (LVEF) was defined as LVEF ≤15%.…”

“…4 Few centers use intra-aortic balloon pump (IABP) routinely for hemodynamic support during unstable VT ablation, although some limited data suggest that IABP support may not be adequate when compared with other newer percutaneous left ventricular assist devices (pLVADs). 5 Alternatives, with more pressure support, are newer pLVADs; however, large prospective studies are lacking.…”

VT ablation: New Developments and Approaches

“…Surgically or percutaneously implanted mechanical circulatory support devices can provide hemodynamic support to allow for more detailed activation and entrainment mapping in patients with unstable VTs. The most common devices being used for mapping unstable VT include [49] (1) the percutaneous ventricular assist device (pVAD) (TandemHeart, Cardiac Assist, Inc., Pittsburg, PA, USA), (2) the Impella microcirculatory axial blood flow pump (Abiomed, Inc., Danvers, MA, USA), (3) the cardiopulmonary support (CPS) with bypass pump, and (4) the intra-aortic balloon pump (IABP). Venoarterial extracorporeal membrane oxygenation (ECMO) is also helpful in supporting the respiratory system in addition to providing circulatory support.…”