Prophylactic mechanical hemodynamic support for catheter ablation of VT: locking the barn door before the horse has bolted

Abstract

In patients with recurrent drug-refractory ventricular tachycardia (VT) in the setting of structural heart disease, radiofrequency catheter ablation (RFCA) has emerged as an important therapeutic strategy to achieve VT suppression and long-term arrhythmia control [1]. In recent years, significant improvements in the techniques and technologies available for RFCA have been paralleled by an increasing number of procedures performed in high-risk and complex patient subsets [1][2][3]. In these subjects, the competing risks associated with the concomitant presence of advanced heart failure syndromes and high burden of associated comorbidities pose substantial periprocedural and post-procedural management challenges [2,3]. In particular, the occurrence of periprocedural acute hemodynamic decompensation (AHD) is a major concern due to its significant association with post-procedural mortality [4]. Each aspect of a VT ablation procedure including induction of anesthesia, programmed ventricular stimulation, presence of spontaneous, and/or mechanically induced VT attempts at pace termination or needs for electrical cardioversions, and fluid overload during mapping and ablation incurs in a potential risk of precipitating AHD resulting in severe end-organ (e.g. brain, kidney, liver) hypoperfusion, and effective therapeutic strategies to prevent the occurrence of this complication are highly warranted.In this issue of JICE, Mathuria et al. report the results of an elegant and well-designed observational study assessing the outcomes of pre-emptive versus rescue use of percutaneous left ventricular assist device (P-LVAD) in a group of 93 patients with structural heart disease undergoing VT ablation [5]. Overall, 36/ 93 (39%) patients received a P-LVAD, with 12 undergoing rescue P-LVAD placement due to periprocedural AHD and the remaining 24 patients who received a P-LVAD prophylactically before the ablation procedure. The patients receiving a P-LVAD were compared with a control group of 57 patients undergoing VT ablation during the same study period and without insertion of a P-LVAD. Interestingly, the authors reported a strikingly higher 30-day mortality rate in the patients who underwent rescue P-LVAD (58%) compared to that in both the pre-emptive P-LVAD (4%) and no P-LVAD (3%) group. Notably, the patients who underwent rescue P-LVAD had a similar risk profile compared to patients who had prophylactic placement of the mechanical support devices. In this regard, the authors used the PAINESD risk score to evaluate differences in clinical profile and risk of periprocedural AHD in their patients (Fig. 1). The PAINESD risk score has been developed by the University of Pennsylvania group in an observational study including 193 consecutive patients undergoing catheter ablation of VT in the setting of structural heart disease [4]. Similar to the findings by Mathuria et al., periprocedural AHD requiring emergent placement of mechanical support devices and/or premature procedure discontinuation was found to have a strong negative prog...

Outcomes of rescue cardiopulmonary support for periprocedural acute hemodynamic decompensation in patients undergoing catheter ablation of electrical storm

“…As such, a prophylactic use of ECMO support in patients deemed at high risk may provide substantial benefits by preventing AHD and allowing a safe completion of the procedure, 9 with a potential for reducing postablation mortality. 10…”