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

Ventricular Arrhythmias in Left Ventricular Assist Device Patients-Current Diagnostic and Therapeutic Considerations

Left ventricular assist devices (LVAD) are used in the treatment of advanced left ventricular heart failure. LVAD can serve as a bridge to orthotopic heart transplantation or as a destination therapy in cases where orthotopic heart transplantation is contraindicated. Ventricular arrhythmias are frequently observed in patients with LVAD. This problem is further compounded as a result of diagnostic difficulties arising from presently available electrocardiographic methods. Due to artifacts from LVAD-generated electromagnetic fields, it can be challenging to assess the origin of arrhythmias in standard ECG tracings. In this article, we will review and discuss common mechanisms, diagnostics methods, and therapeutic strategies for ventricular arrhythmia treatment, as well as numerous problems we face in LVAD implant patients.

Evolution of Mechanical Circulatory Support for advanced heart failure

This comprehensive review highlights the significant advancements in Left Ventricular Assist Device (LVAD) therapy, emphasizing its evolution from the early pulsatile flow systems to the cutting-edge continuous-flow devices, particularly the HeartMate 3 (HM3) LVAD. These advancements have notably improved survival rates, reduced complications, and enhanced the quality of life (QoL) for patients with advanced heart failure. The dual role of LVADs, as a bridge-to-transplantation and destination therapy is discussed, highlighting the changing trends and policies in their application. The marked reduction in hemocompatibility-related adverse events (HRAE) with the HM3 LVAD, compared to previous models signifies ongoing progress in the field. Challenges such as managing major infections are discussed, including innovative solutions like energy transfer systems aimed at eliminating external drivelines. It explores various LVAD-associated complications, including HRAE, infections, hemodynamic-related adverse events, and cardiac arrhythmias, and underscores emerging strategies for predicting post-implantation outcomes, fostering a more individualized patient care approach. Tools such as the HM3 risk score are introduced for predicting survival based on pre-implant factors, along with advanced imaging techniques for improved complication prediction. Additionally, the review highlights potential new technologies and therapies in LVAD management, such as hemodynamic ramp tests for optimal speed adjustment and advanced remote monitoring systems. The goal is to automate LVAD speed adjustments based on real-time hemodynamic measurements, indicating a shift towards more effective, patient-centered therapy. The review concludes optimistically that ongoing research and potential future innovations hold the promise of revolutionizing heart failure management, paving the way for more effective and personalized treatment modalities.

Urgent catheter ablation in Japanese patients with mechanical circulatory supports suffering from refractory ventricular electrical storm

BACKGROUND

Therapeutic strategy using catheter ablation for ventricular tachyarrhythmias (VTAs) electrical storms in patients dependent on percutaneous mechanical circulatory support (MCS) has not yet been established.

METHODS

We reviewed the patients with or without requiring MCS who received urgent VTAs ablation in our institute between January 2020 and May 2022. Electrophysiological and clinical outcomes were compared between those with and without requiring MCS.

RESULTS

Twenty procedures (16 patients, median 76 years, 13 males) were included. Six procedures using MCS underwent ablations and the other 14 procedures were performed without MCS. Although VTAs cycle lengths were not significantly different between the two groups, the incidence of hemodynamic stability was significantly higher in MCS group than in those without (83 % vs. 29 %, p = 0.024). Temporary MCS were explanted in all patients following the successful ablation, whereas the complication rates were higher in patients requiring MCS (67 % vs. 0 %, p = 0.001). Cumulative incidences of cardiovascular death and appropriate therapy of implantable cardioverter defibrillator within 90 days following the procedures were not significantly different between the two groups (p = 0.071 and p = 0.063, respectively).

CONCLUSION

Urgent ablation might be a feasible bail out option for those dependent on MCS suffering from VTAs, although physicians should be on high alert for device-related bleeding.