Catheter Ablation in Patients With Cardiogenic Shock and Refractory Ventricular Tachycardia

Abstract

Background: There is paucity of data regarding radiofrequency ablation for ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to antiarrhythmic drugs on mechanical support. Methods: Patients undergoing VT ablation at our center were enrolled in a prospectively maintained registry and screened for the current study (2010–2017). Results: All 21 consecutive patients with cardiogenic shock and concomitant refractory ventricular arrhythmia undergoing bailout ablation due to inability to wean off mechanical support were included. Median age was 61 years, 86% were men, median left ventricular ejection fraction was 20%, 81% had ischemic cardiomyopathy, and PAINESD score was 18±5. The type of mechanical support in place before the procedure was intra-aortic balloon pump in 14 patients (67%), Impella CP in 2, extracorporeal membrane oxygenation in 2, extracorporeal membrane oxygenation and intra-aortic balloon pump in 2, and extracorporeal membrane oxygenation and Impella CP in 1. Endocardial voltage maps showed myocardial scar in 19 patients (90%). The clinical VTs were inducible in 13 patients (62%), whereas 6 patients had premature ventricular contraction–induced ventricular fibrillation/VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 with inducible clinical VTs. Substrate modification was performed in 15 patients with scar (79%). After ablation and scar modification, the arrhythmia was noninducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully, but 6 (29%) died during the index admission from persistent cardiogenic shock. Patients who had ventricular arrhythmia and cardiogenic shock on presentation had a trend toward lower in-hospital mortality compared with those who presented with cardiogenic shock and later developed ventricular arrhythmia. Conclusions: Bailout ablation for refractory ventricular arrhythmia in cardiogenic shock allowed successful weaning from mechanical support in a large proportion of patients. Mortality remains high, but the majority of patients were discharged home and survived beyond 1 year.

Extracorporeal Membrane Oxygenation-Impella (ECPELLA) in a Patient With Recalcitrant Ventricular Tachycardia Undergoing Ablation

“…MCS options that can be used for hemodynamically unstable VT ablation described in the literature are the intra-aortic balloon pump (IABP), Impella 2.5, or CP, which only provide up to 2.5-3.5 L/min of flow. The most clinical experience thus far with VT ablation has been with the Impella 2.5 device [ 5 , 6 ]. Hemodynamic support aims to maintain adequate end-organ perfusion during prolonged episodes of ventricular tachycardia, thereby allowing detailed circuit mapping.…”

Electrical Storm Ablation in a Patient in Cardiogenic Shock Supported by Impella 5.0

“…The only reliable treatment at this point was the radiofrequency intervention ( 7 , 8 ). Indeed, specific data on ablation in the setting of cardiogenic shock requiring ventricular assistance are limited ( 9 ). Despite the high mortality reported in patients with implanted LVADs who present with electrical storm, this case suggests that monomorphic ventricular arrhythmia can be successfully treated in the presence of an Impella 5.0 device, thus allowing subsequent implantation of long-term mechanical cardiac support ( 10 ).…”

Cardiopulmonary Support During Catheter Ablation of Ventricular Arrhythmias With Hemodynamic Instability: The Role of Inducibility

“…Most published articles investigated outcomes of emergent cardiopulmonary support with ECMO to rescue acute heart decompensation in patients undergoing catheter ablation of ES showing that ECMO support was associated with poor outcomes when used as a rescue intervention for acute heart decompensation despite hemodynamic stabilization and effective acute arrhythmia suppression ( 8 , 10 – 14 ). In particular, the majority of patients studied died of refractory heart failure in the short-term follow-up.…”

“…Catheter ablation for ES can reduce recurrent episodes of ventricular arrhythmias (VAs) and improve patient prognoses ( 4 – 7 ); however, patients with hemodynamically unstable VAs have a rate of procedural complications and mortality. Recent data suggest that cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) can provide valuable support during catheter ablation procedures in this setting ( 8 – 14 ). In particular, the ECMO system is useful for managing intraoperative acute hemodynamic decompensation and can facilitate the accurate mapping and ablation of unstable VAs.…”