A Review of New-Onset Ventricular Arrhythmia after Left Ventricular Assist Device Implantation

Abstract

<b><i>Introduction:</i></b> Heart failure (HF) is a severe and terminal stage of various heart diseases. Left ventricular assist devices (LVADs) are relatively mature and have contributed to the treatment of end-stage HF. Ventricular arrhythmia (VA) is a common complication after LVAD implantation, including ventricular tachycardia and ventricular fibrillation, both of which may cause abnormal circulation. <b><i>Methods:</i></b> A literature search was conducted in the PubMed database, “Ventricular Arrhythmia” OR “VA” OR “Arrhythmia” OR “Ventricular Tachycardia,” OR “Ventricular Fibrillation” AND “LVAD” OR “Left Ventricular Assist Device” OR “Heart Assist Device” as either keywords or MeSH terms, the authors screened the titles and abstracts of the articles. Eventually, 12 original research articles were retrieved. <b><i>Results:</i></b> The 0.83 [95% CI: 0.77, 0.89] of patients were male. A whole of 53% [95% CI: 0.25, 0.81] of VA patients had a history of atrial fibrillation and 61% [95% CI: 0.52, 0.69] had a history of VA. 39% [95% CI: 0.29, 0.49] of the participants had no prior history of VA and experienced new VA following CF-LVAD implantation. Following CF-LVAD implantation, 59% [95% CI: 0.51, 0.67] of patients developed early VA (VA ≤30 days). The 30-day mortality rate of patients was 4% [95% CI: 0.01, 0.07]. And overall mortality was 28% [95% CI: 0.15, 0.41]. The reported incidence of VA after LVAD implantation is not identical in different medical centers and ranges from 20% to 60%. The mechanism of VA after LVAD implantation is summarized as primary cardiomyopathy-related, device mechanical stimulation, myocardial scarring, ventricular displacement, electrolyte regulation, and other processes. <b><i>Conclusions:</i></b> A preoperative VA history is considered a predictor of VA following LVAD implantation in most studies. Multiple mechanisms and factors, such as prevention of “suction events,” ablation, and implantable cardioverter defibrillator, should be considered for the prevention and treatment of postoperative VA in patients requiring long-term VAD treatment. This study provides a reference for the clinical application of LAVD and the prevention of postoperative VA after LVAD implantation. Future multicenter prospective studies with uniform patient follow-up are needed to screen for additional potential risk factors and predictors. These studies will help to define the incidence rate of VA after LAVD implantation. As a result, we provide guidance for the selection of preventive intervention.

Mechanical circulatory support in ventricular arrhythmias

“…In fact, the persistence of ventricular arrhythmia in these patients may cause right heart dysfunction, ultimately leading to hemodynamic compromise (51). From a mortality point of view, the presence of ventricular arrhythmias after LVAD implantation did not affect short-term mortality but significantly increased longterm one (52). Proposed mechanisms for developing ventricular arrhythmias in these patients are multiple and encompass (51,53): preload alteration with chamber collapse and "suctionrelated" VT, changes in myocardial electrolyte balance, primary cardiomyopathy, device-related mechanical stimulation, and hypersympathetic state.…”

“…Predictors of post-operative ventricular arrhythmias after the implantation of LVAD are the history of pre-LVAD ventricular arrhythmias and duration of heart failure ( 54 – 56 ), and the role of underlying cardiomyopathy type is still debated. The findings regarding the onset of ventricular arrhythmias after the implantation of LVAD have been recently summarized in a review ( 52 ).…”

The role of atria in ventricular fibrillation after continuous-flow left ventricular assist device implantation in ovine model

“…Mechanical circulatory support (MCS) with continuous-flow left ventricular assist device (CF-LVAD) has been preferably used as a “bridge” device before a heart transplantation and regarded as one of the long-term treatment options for patients with end-stage heart failure. Nonetheless, ventricular arrhythmias (VA) including ventricular fibrillation (VF) which is common in malignant arrhythmias, are frequent after CF-LVAD implantation with an incidence of about 20–60% ( 1 , 2 ). Under normal physiological status, VF is considered as the main causative factor of sudden cardiac death, as it leads to disappearance of ventricular systolic function and complete loss of cardiac output resulting in severe hemodynamic collapse.…”

Mechanistic assessment and ablation of left ventricular assist device related ventricular tachycardia in patients with severe heart failure

“…Novel devices use centrifugal continuous flow and have been associated with improved outcomes in patients with heart failure and lvad for destination therapy. However, HF patients with lvad have significant myocardial substrate for ventricular arrhythmias and the apical inflow canula and the suture line of the fixation ring of the lvad itself might contribute to pro-arrhythmogenic substrate ( Shi et al, 2022 ).…”