Prophylactic mechanical circulatory support for protected ventricular tachycardia ablation: A meta‐analysis of the literature

Abstract

Acute hemodynamic decompensation (AHD) during ventricular tachycardia (VT) ablation occurs in about 11% of cases. Prophylactic use of temporary mechanical circulatory support (pro‐tMCS) has been applied to prevent AHD during VT ablation, but evidence supporting this practice is still lacking. This systematic review and meta‐analysis assessed the procedural characteristics and outcomes of pro‐tMCS for VT ablation. PubMed/Medline was screened until February 2020. Articles including adults receiving pro‐tMCS for VT ablation were included, and a meta‐analysis to compare proMCS and no‐tMCS was performed. Primary outcome was in‐hospital/30‐day mortality. Five observational studies presenting 400 procedures (pro‐tMCS: n = 187; no‐tMCS: n = 213) were included. Baseline characteristics were comparable between groups. Impella and TandemHeart were used in 86.6% and 13.4% of cases, respectively. In the pro‐tMCS group, more VTs were induced (mean difference: 0.52, confidence interval [CI]: 0.26‐0.77, P < .0001), and patients remained in VT on average for 24.04 minutes longer (CI: 18.28‐29.80, P < .00001). Procedural success was comparable between groups, as was VT recurrence. Pro‐tMCS patients had an odds ratio of 0.55 (CI: 0.28‐1.05, P = .07) for in‐hospital/30‐day mortality and 0.55 (CI: 0.32‐0.94, P = .03) for mortality at follow‐up. Sixty‐four percent of no‐tMCS patients received rescue tMCS. The most common tMCS‐related complications were bleeding events. Pro‐tMCS allowed for a prolonged time on VTs and the induction of more VTs. Although these advantages were not associated with differences in procedural success, VT recurrence, or in‐hospital/30‐day mortality in the overall population, pro‐tMCS might improve long‐term survival. Further prospective studies are urgently needed to confirm these results.

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery

“…Finally, with respect to life-threatening arrhythmias such as ventricular tachycardia (VT), TandemHeart is the second most used pVAD after the Impella device in protected VT ablation [ 71 ]. Advantages of pVADs’ implantation include the maintenance of end-organ perfusion during VT for longer periods, which require fewer terminations of VT (anti-tachycardia pacing), thus increasing the likelihood that VT ends during ablation [ 25 ].…”

“…Advantages of pVADs’ implantation include the maintenance of end-organ perfusion during VT for longer periods, which require fewer terminations of VT (anti-tachycardia pacing), thus increasing the likelihood that VT ends during ablation [ 25 ]. Although these advantages have not been shown to prevent VT recurrence, in-hospital/30-day mortality or procedural success compared to control patients suggested that patients receiving pVADs during protected ablation might experience a reduced risk of long-term mortality [ 71 , 72 ]. Studies also demonstrate that preemptive implantation of Impella or TandemHeart in patients with systolic heart failure can prolong the time on VTs and induce a greater number of VTs [ 71 , 72 ].…”

“…Although these advantages have not been shown to prevent VT recurrence, in-hospital/30-day mortality or procedural success compared to control patients suggested that patients receiving pVADs during protected ablation might experience a reduced risk of long-term mortality [ 71 , 72 ]. Studies also demonstrate that preemptive implantation of Impella or TandemHeart in patients with systolic heart failure can prolong the time on VTs and induce a greater number of VTs [ 71 , 72 ]. Furthermore, a meta-analysis comprising 69 patients, demonstrated that the delayed removal of pVADs in patients undergoing catheter ablation of ventricular tachycardia is associated with increased 90-day mortality [ 41 ].…”

The 10 Commandments of Microaxial Temporary Left Ventricular Assist Devices

“…Impella devices have also been utilized to prophylactically prevent hemodynamic decompensation during high-risk electrophysiologic procedures, most frequently during ventricular tachycardia (VT) ablations. 9 A secondary benefit of this approach is enabling more prolonged time in VT and induction of more VT in patients with low ejection fraction. While Impella 2.5 and CP are most frequently utilized for these cases, use of the Impella 5.0 and 5.5 for protected ablations has also been described.…”

Outcomes of mechanical circulatory support for ventricular tachycardia ablation in severe systolic heart failure

“…(3) It is not clear if use of pVAD was performed preemptively or as a rescue. This is important because emergent use of pVAD has been shown to be associated with worse outcomes [5,8,9]. (4) The authors mention that the most prevalent cause of death was progressive shock or refractory HF.…”