Concomitant surgical cryoablation for refractory ventricular tachycardia and left ventricular assist device placement: a dual remedy but a recipe for thrombosis?

Abstract

BackgroundVentricular tachycardia (VT) can persist following placement of a left ventricular assist device (LVAD). The optimal management strategy for VT during the peri-LVAD period is unknown.Case PresentationsTwo case reports are presented that describe epicardial and endocardial VT ablation performed during LVAD placement. Subsequently, both patients developed LVAD thrombosis, a known and dreaded complication of LVADs, requiring re-operation.ConclusionsWhile LVAD thrombosis is likely multifactorial and remains an area of active research, these two cases should increase awareness of the possible risks of VT ablation—especially endocardial ablation—during LVAD placement. Further research is needed to understand the effects of VT ablation during the peri-LVAD period.

Massive myocardial edema and inflow cannula obstruction due to epicardial surgical ventricular tachycardia cryoablation at time of left ventricular assist device implantation

“…Although there are a number of anecdotal reports of this approach, there are small case series that have been published. 4 , 5 , 6 , 7 …”

“…The third study was of 2 patients who underwent endocardial and epicardial cryoablation. 6 Both had successful ablation procedures but were complicated by LVAD thrombosis post implant, although this may have been related to the LVAD device type, which has been shown to predispose patients to a significantly higher risk of VAD thrombosis than newer-generation LVADs.…”

Left ventricular assist device exchange for the treatment of HeartMate II pump thrombosis

“…Since atrial fibrillation is a risk factor for thrombus (23). Concomitant cryoablation for tachycardias combined with LVAD implantation has been described before (24) and might be a solution to reduce the risk of pump thrombosis in patients with AF. Anticoagulation is a major factor in preventing pump thrombosis.…”

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

“…Limited case series have examined the role of epicardial cryoablation at the time of LVAD implantation without systematic electroanatomic mapping . Mulloy et al performed intraoperative epicardial and endocardial cryoablation during HeartMate II implant in seven patients with recurrent preoperative VA who subsequently developed less postimplant arrhythmias and complications when compared to seven historical controls.…”

“…The ability to more accurately identify either before or during LVAD implant those patients at high risk for developing postimplant VA may improve LVAD outcomes. Several case series have reported the feasibility of intraoperative or perioperative VT ablation, but are limited by a lack of systematic high‐density intraoperative mapping . The aims of the present study are: To describe the feasibility of a safe and expeditious intraoperative protocol for high‐density multielectrode mapping of the epicardial substrate. To investigate any relationships between epicardial voltage characteristics and incidence of postimplant VA.…”