Insight into Atrial Fibrillation in LVAD Patients: From Clinical Implications to Prognosis

Sisti, Nicolò; Mandoli, Giulia Elena; Sciaccaluga, Carlotta; Valente, Serafina; Mondillo, Sergio; Cameli, Matteo

doi:10.1159/000506600

Cited by 8 publications

(10 citation statements)

References 77 publications

(104 reference statements)

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“…Although the general management of AAs is well-reported for non-LVAD heart failure patients, managing LVAD patients seems to be entirely different. [ 8 ] The effects of rate control in LVAD patients are unproven, but the consensus is that beta blockers are usually used in LVAD patients who have AF. [ 4 ] The combination of beta blockers and digoxin is typically approved for the management of AF.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…Furthermore, we should consider applying RFCA as early first-line treatment in LVAD patients for both symptomatic and clinical improvement, due to side effects of the rate and rhythm controlling drugs. [3,[8][9][10] The major limitation to this study is the practicality in identifying the timing of intervention. Atrial arrhythmia commonly occurs concurrently in patients with heart failure and oftentimes antiarrhythmic drugs are used as first-line treatment.…”

Section: Discussionmentioning

confidence: 99%

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Catheter ablation for atrial fibrillation in left ventricular assist device

2021

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Introduction: Mechanical circulatory support such as the left ventricular assist device (LVAD) has become widely implemented in the treatment of end-stage heart failure, whether as bridge-to-transplant or as destination therapy. The hemodynamic effects of arrhythmia on LVADs and its management are significant in determining the long-term outcome of these patients. Both atrial arrhythmia and ventricular arrhythmia are commonly seen after implantation of the device. There are no strict guidelines, however, on the need for intensive management of arrhythmias in LVAD. In this case report, we present a patient with new onset atrial fibrillation after LVAD implantation which leads to acute decompensating heart failure. The patient was treated with catheter ablation. The intervention demonstrated positive outcomes for this patient. Patient concerns: The patient was a Korean male, who presented with dyspnea, fatigue and generalized edema after persistent atrial fibrillation precipitated by implantation of the left ventricular assist device. Diagnosis: The patient was diagnosed with acute decompensating heart failure that was aggravated by recurrent atrial arrhythmia. Intervention: We attempted to relieve symptoms of right ventricular dysfunction by method of strict rhythm control in this patient. The patient underwent radiofrequency catheter ablation for recurrent atrial fibrillation. Outcome: The patient showed improved clinical symptoms, BNP levels, and echocardiogram parameters immediately after the procedure as well as during long term outpatient follow up. Conclusion: In this case report, we present the first successful case in Korea of atrial fibrillation in LVAD treated with catheter ablation. This case suggests setting catheter ablation as a routine first-line treatment for atrial arrhythmia in LVAD patients, especially when the arrhythmia predisposes the patient at risk for decompensating heart failure.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Catheter ablation for atrial fibrillation in left ventricular assist device

2021

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“…VWF multimers bind to the collagen on damaged blood vessels, then platelets bind to the VWF causing platelet activation, adhesion, aggregation and thrombosis to prevent bleeding (Geisen et al, 2008). Acquired von Willebrand functional deficiency syndrome, specifically type 2A which is associated with LVAD devices, occurs as a result of the high local shear stress and blood flowing over the non‐biological surfaces of the device which increases platelet activation (Sisti et al, 2020). The increased shear stress causes structural changes in the shape of the vWF exposing the bonds between the amino acids thus leading to proteolysis of the highest molecular weight multimers of vWF which are the most active in haemostasis by the enzyme ADAMTS‐13 (Adatya & Bennett, 2015).…”

Section: Adverse Events—lvad‐related Blood Coagulopathymentioning

confidence: 99%

Advancements in left ventricular assist devices to prevent pump thrombosis and blood coagulopathy

Malone¹,

Abdelsayed²,

Bligh³

et al. 2022

Journal of Anatomy

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Mechanical circulatory support (MCS) devices, such as left ventricular assist devices (LVADs) are very useful in improving outcomes in patients with advanced‐stage heart failure. Despite recent advances in LVAD development, pump thrombosis is one of the most severe adverse events caused by LVADs. The contact of blood with artificial materials of LVAD pumps and cannulas triggers the coagulation cascade. Heat spots, for example, produced by mechanical bearings are often subjected to thrombus build‐up when low‐flow situations impair washout and thus the necessary cooling does not happen. The formation of thrombus in an LVAD may compromise its function, causing a drop in flow and pumping power leading to failure of the LVAD, if left unattended. If a clot becomes dislodged and circulates in the bloodstream, it may disturb the flow or occlude the blood vessels in vital organs and cause internal damage that could be fatal, for example, ischemic stroke. That is why patients with LVADs are on anti‐coagulant medication. However, the anti‐coagulants can cause a set of issues for the patient—an example of gastrointestinal (GI) bleeding is given in illustration. On account of this, these devices are only used as a last resort in clinical practice. It is, therefore, necessary to develop devices with better mechanics of blood flow, performance and hemocompatibility. This paper discusses the development of LVADs through landmark clinical trials in detail and describes the evolution of device design to reduce the risk of pump thrombosis and achieve better hemocompatibility. Whilst driveline infection, right heart failure and arrhythmias have been recognised as LVAD‐related complications, this paper focuses on complications related to pump thrombosis, especially blood coagulopathy in detail and potential strategies to mitigate this complication. Furthermore, it also discusses the LVAD implantation techniques and their anatomical challenges.

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“…According to literature, the following are the most important predictors of VAs during the 12 months after implantation: history of VAs during pre‐LVAD period, pre‐implant atrial fibrillation, heart failure lasting more than 12 months, no therapy with ACE inhibitors and betablockers 4,24,35‐37 . In all the reviewed reports, the presence of VAs was associated with a significant increase in all‐cause mortality (HR 7.28; 95% CI 3.50‐15.15; P = .001).…”

Section: Predictors Of Arrhythmia In Lvad Patientsmentioning

confidence: 99%

Ablation therapy for ventricular arrhythmias in patients with LVAD: Multiple faces of an electrophysiological challenge

Sisti

Santoro

Carreras

et al. 2021

Journal of Arrhythmia

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Left ventricular assist device implantation is a recognized treatment option for patients with advanced heart failure refractory to medical therapy and can be used both as bridge to transplantation and as destination therapy. The risk of ventricular arrhythmias is common after left ventricular assist device implantation and is influenced by pre‐, peri and post‐operative determinants. The management of ventricular arrhythmias can be a challenge when they become refractory to medication or to device therapy and their impact on prognosis can be detrimental despite the mechanical support. In this setting, catheter ablation is being increasingly recognized as a feasible option for patients in which standard therapeutic strategies fail, but also with preventive purpose. Catheter ablation is being increasingly considered for the management of ventricular arrhythmias in patients with left ventricular assist device despite complex clinical and technical peculiarities due to the characteristics of the mechanical support. Much conflicting data exist regarding the predictors of success of the procedure and the rate of recurrence. In this review we discuss the latest evidences regarding catheter ablation of ventricular arrhythmias in this subset of patients, focusing on clinical characteristics, arrhythmia etiology, technical aspects and postprocedural features which must be considered by the electrophysiologist.

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Insight into Atrial Fibrillation in LVAD Patients: From Clinical Implications to Prognosis

Cited by 8 publications

References 77 publications

Catheter ablation for atrial fibrillation in left ventricular assist device

Catheter ablation for atrial fibrillation in left ventricular assist device

Advancements in left ventricular assist devices to prevent pump thrombosis and blood coagulopathy

Ablation therapy for ventricular arrhythmias in patients with LVAD: Multiple faces of an electrophysiological challenge

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