Catheter Ablation for Ventricular Tachyarrhythmias in Patients Supported by Continuous-Flow Left Ventricular Assist Devices

Abstract

Ventricular arrhythmias (VAs) are common after implantation of a left ventricular assist device (LVAD) and in a subset of patients may be refractory to medication. Morbidity from VA in this population includes right ventricular failure (RVF). We sought to evaluate the efficacy of catheter ablation for VA in patients with LVAD. A retrospective analysis of patients supported by continuous-flow LVAD referred for catheter ablation of ventricular tachycardia (VT) between 2008 and the present was performed. Seven patients were referred for VT ablation an average of 236 ± 292 days after LVAD implantation. Three patients (42.9%) developed RVF in the setting of intractable arrhythmias. A transfemoral approach was used for six patients (85.7%) and an epicardial for one patient (14.3%). The clinical VT was inducible and successfully ablated in six patients (85.7%). The location of these arrhythmias was apical in three cases (42.9%). A total of 13 VTs were ablated in seven patients. Although the majority had reduction in VA frequency, recurrent VAs were observed in six patients (85.7%). One patient (14.3%) experienced a bleeding complication after the procedure. For patients with a high VA burden after LVAD implantation, VT ablation is safe and feasible, but VA frequently recurs.

Incidence and clinical significance of late right heart failure during continuous-flow left ventricular assist device support

“…Indeed, patients in the RHF group more frequently required re-admission due to cardiac tachyarrhythmia that may lead to worsening right ventricular function. 17 Other adverse events, including infection and device failure, were also common during longterm LVAD support. These late adverse events may contribute to the development of late RHF as a chronic aggravating factor.…”

Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation

“…With the older generation HeartMate LVAD, VA after LVAD placement was thought to involve substrate around the apical inflow cannula in many cases, but analysis was largely based on 12 lead EKG localization . Small, early series of endocardial VT ablation after LVAD placement suggested that VT is not associated with the apical inflow cannula in a majority of cases . More recent, larger series including continuous flow LVAD models have confirmed that late VT is often associated with pre‐existing intrinsic scar remote from the inflow cannula, and catheter ablation in these areas terminates over half of induced VT, whereas cannula‐associated arrhythmia accounted for only 9% to 24% of cases …”

Epicardial Catheter Ablation Through Subxiphoid Surgical Approach in a Patient With Implanted Left Ventricular Assist Device and Cannula-Related Ventricular Tachycardia

“…1 In patients with ischemic cardiomyopathy, re-entrant VT can often be ablated endocardially near areas of electric scar associated with previous myocardial infarction. However, in nonischemic cardiomyopathy, epicardial distribution of scar and sites of origin for VT is comparatively more frequent.…”