Percutaneous Hemodynamic Support With Impella 2.5 During Scar-Related Ventricular Tachycardia Ablation (PERMIT 1)

Abstract

Background-Percutaneous left ventricular assist devices (pLVADs) are increasingly being used to facilitate ablation of unstable ventricular tachycardia (VT), but the safety profile and hemodynamic benefits of these devices have not been described in a systematic, prospective manner. Methods and Results-Twenty patients with scar VT underwent ablation with a pLVAD. Neuromonitoring using cerebral oximetry was performed to evaluate a cerebral desaturation threshold to guide the duration of activation/entrainment mapping. The efficacy of pLVAD support was tested in a controlled manner with simulated VT. Complete procedural success was achieved in 50% (n=8) of patients, who were initially inducible for sustained VT, and partial procedural success in 37% (n=6). Using a cerebral desaturation level of 55% as a lower safety limit to guide the duration of sustained VT, 3 patients (15%) developed mild acute kidney injury (all resolved), and 1 (5%) patient developed mild cognitive dysfunction. During fast simulated VT (300 ms), cerebral desaturation to ≤55% occurred in more than half (53%) of patients tested without pLVAD support, compared with only 5% with full pLVAD support (P=0.003). Conclusions-In a consecutive series of patients with severe left ventricular dysfunction, pLVAD-supported scar VT ablation was safe and feasible. During fast simulated VT, a miniaturized axial flow pump imparted a more favorable hemodynamic profile compared with pharmacological agents alone. Cerebral oximetry is a complimentary monitoring modality during scar VT ablation, and avoidance of cerebral desaturations below a threshold of 55% may safely guide the duration of mapping during unstable VT. (Circ Arrhythm Electrophysiol. 2013;6:151-159.)

Outcomes of Ventricular Tachycardia Ablation Using Percutaneous Left Ventricular Assist Devices

“…In a prospective evaluation of pLVADs, patients were maintained in VT for nearly 1 hour. 12 These findings are similar to those of other investigators. [11][12][13][14] Common to these studies is the finding that pLVAD use provided no evidence of benefit in terms of postablation inducibility or freedom from recurrent VT compared with ablation without pLVAD support, although fewer comorbidities were present in cases without pLVAD support.…”

“…[1][2][3][4][5][6][7][8][9] To facilitate entrainment and activation mapping of hemodynamically unstable VT and mitigate the effects of frequent induction and prolonged VT duration on end-organ perfusion, several studies have demonstrated the feasibility of percutaneous left ventricular assist devices (pLVADs) for hemodynamic support during ablation procedures. [10][11][12][13][14] In these studies, pLVAD support resulted in increased mapping time during VT, less requirement for VT termination because of hemodynamic instability, and more VT terminations during ablation. However, there is limited data to ascertain whether this acute hemodynamic benefit translates into improved clinical outcomes.…”

Anesthetic Management in Radiofrequency Catheter Ablation of Ventricular Tachycardia

“…2). 30,31 Limitations apply when using these devices in VT ablation. The TandemHeart's transseptal placement precludes the same access for ablation catheters, so only the retrograde approach from the femoral artery is feasible.…”

2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American heart assocation, the cardiological society of India, and sociedad latino Americana de cardiologia intervencion; Affirmation of value by the canadian association of interventional cardiology–association canadienne de cardiologie d'intervention)

“…In the adult population, patients with severe, nonoperable valve disease represent a rapidly growing population; carefully selected patients may benefit from cardiac support during percutaneous aortic valvuloplasty or aortic valve replacement [31,32]. Similarly, patients referred for electrophysiologic procedures with severe underling LV dysfunction may not tolerate sustained arrhythmias during prolonged electrophysiological mapping and ablation procedures [33,34]. Finally, patients with right ventricular (RV) failure are at considerably higher risk for morbidity and mortality when presenting with AMI, ADHF, or CS.…”