Extracorporeal Membrane Oxygenation for Hemodynamic Support of Ventricular Tachycardia Ablation

Abstract

Background-We report the experience in a cohort of consecutive patients receiving extracorporeal membrane oxygenation during catheter ablation of unstable ventricular tachycardia (VT) at our center. Methods and Results-From 2010 to 2015, extracorporeal membrane oxygenation was initiated in 64 patients (average age: 63±15 years; left ventricular ejection fraction in 27±9%; cardiogenic shock in 23%, and electrical storm in 62% of patients) undergoing 74 unstable VT catheter ablation procedures. At least one VT was terminated in 81% of procedures with baseline inducible VT, and VT noninducibility was achieved in 69%. Acute heart failure occurred in 5 patients: 3 underwent emergency heart transplantation, 1 had left ventricular assist device (LVAD) implantation, and 1 patient eventually died because of subsequent mesenteric ischemia. All other patients were discharged alive. After a median follow-up of 21 months (13-28 months), VT recurrence was 33%; overall survival was 56 out of 64 patients (88%). Extracorporeal membrane oxygenation-supported ablation was the bridge to LVAD in 6.9% and to heart transplantation in 3.5% of patients. VT recurrence was related to ablation success (after 180 days of follow up: 19% when VT was noninducible, 42% if nonclinical VT was inducible, 75% when clinical VT was inducible, and 75% in untested patients, P<0.001). Incidence of all-cause death, heart transplantation, and LVAD was independently related to ablation outcome (at 180 days of follow-up: 9% when noninducibility was achieved, 50% in case of inducible VT, and 75% in untested patients, P<0.001). At multivariable analyses, noninducibility (hazard ratio 0.198; P=0.001) and left ventricular ejection fraction (hazard ratio 0.916; P=0.008) correlated with all-cause death, LVAD, and heart transplantation. Conclusions-Ablation of unstable VTs can be safely supported by extracorporeal membrane oxygenation, which allows rhythm stabilization with low procedure mortality, bridging decompensated patients to permanent LVAD or heart transplantation. Successful ablation is associated with better outcomes than unsuccessful ablation.(Circ Arrhythm Electrophysiol. 2016;9:e004492.

Late potentials abolition reduces ventricular tachycardia recurrence after ablation especially in higher‐risk patients with a chronic total occlusion in an infarct‐related artery

“…Moreover, hemodynamic deterioration in patients with multiple and recurrent VT during the procedure is often a limiting factor that can prevent complete substrate elimination. With respect to this, it has been demonstrated that elective hemodynamic support with ECMO is safe and may be useful in high risk patients, allowing to continue ablation until a complete substrate abolition is achieved.…”

Electrical Storm in Patients with Implantable Cardioverter-defibrillators: A Practical Overview

“…49 The PAI-NESD score has been validated in a cohort of 93 patients who presented with VT in the setting of structural heart disease and who were divided into three groupsprophylactic, rescue, and no percutaneous LVAD placement-for evaluation. 50 In this study, patients who underwent rescue LVAD had a significantly higher 30-day mortality rate (58%) compared with patients who underwent prophylactic LVAD (4%), even if they had similar PAINESD scores (mean: 17.8 versus 16.5). Moreover, 30-day mortality among patients who underwent prophylactic LVAD was superimposable to mortality among patients who were ablated without LVAD support (3%), even if the latter had a significantly lower PAINESD score (mean: 13.4), thus highlighting the importance of using prophylactic mechanical support in highrisk patients to improve postprocedural mortality.…”

“…Moreover, 30-day mortality among patients who underwent prophylactic LVAD was superimposable to mortality among patients who were ablated without LVAD support (3%), even if the latter had a significantly lower PAINESD score (mean: 13.4), thus highlighting the importance of using prophylactic mechanical support in highrisk patients to improve postprocedural mortality. 50 However, some patients with advanced HF have significant biventricular dysfunction, and LVAD support may be inadequate. In these cases, devices providing biventricular support, including ECMO, should be considered.…”

“…In a recent study involving 64 patients undergoing CA of unstable VTs, the prophylactic use of ECMO allowed for procedure completion in 92% of patients, the achievement of VT non-inducibility in 69%, and an 88% overall survival rate at 21 months' follow-up. 50 …”

A Peripheral Blood Transcriptome Biomarker Test to Diagnose Functional Recovery Potential in Advanced Heart Failure

“…A major challenge of VT ablation is hemodynamic intolerance of the induced arrhythmia, with as few as 10% of induced arrhythmias being stable. Short-term hemodynamic support such as percutaneous temporary ventricular support devices (e.g., Impella R ) and extracorporeal membrane oxygenation (ECMO) will be increasingly used in this scenario [47]. The challenge is to predict a prohibitively high risk of not being able to wean the patient from veno-arterial (VA)-extracorporeal membrane oxygenation postinterventionally.…”