Keywords
Introduction
Left ventricular assist devices (LVADs) are a therapy for patients with advanced heart failure (HF). Ventricular arrhythmias (VA) occur in up to 50% of patients following LVAD implantation.
1
They are multifactorial in origin, including arrhythmogenic substrate from the underlying cardiomyopathy, LVAD-induced apical scarring around the inflow cannula, suction events, mechanical trauma, and immediate postoperative changes. VA in the post-LVAD setting is associated with increased morbidity and mortality.2
Limited data supports catheter ablation in this population.
3
VA ablation is often limited owing to technical challenges including catheter entrapment, maneuvering, and mapping interference.2
Nevertheless, data suggest potential benefits in post-LVAD survival and freedom from significant ventricular tachycardia (VT).4
Most catheter-based VA ablations occur either before or after LVAD implantation; what remains less investigated is intraoperative VA ablation. Endocardial and/or epicardial access during LVAD implantation may avoid the technical difficulties of a standard LVAD VT ablation and prevent subsequent higher-risk open/hybrid epicardial VA ablations.
5
Case report
We describe our single-center experience with intraoperative VT ablation at the time of LVAD implantation. We retrospectively reviewed all implanted LVADs from 2012 to 2022 (n = 725) and identified 6 patients.
Appropriate institutional review board approval was obtained and patients were screened for inclusion by querying the advanced HF database (Ascension St. Vincent Heart Center, Indianapolis, IN). CPT codes for LVAD placement (33979) and intraoperative VA ablation (93654) were cross-referenced to increase accuracy.
Results
Of 6 patients, 2 were implanted with a HeartMate II device, 1 with an HM 3, and 3 with Medtronic HeartWare ventricular assist devices. All patients underwent endocardial cryoablation in the left ventricle, with 1 undergoing epicardial ablation. Additional patient characteristics are detailed in Table 1. All patients were on appropriate warfarin therapy per standard protocol after LVAD implantation. Worsening VA was the driver for urgent LVAD implant in all patients.
Table 1Baseline patient characteristics
| Total number of patients | 6 |
| Male | 83% |
| Ischemic cardiomyopathy | 50% |
| NICM | 50% |
| Heart transplant recipients | 50% |
| Mean age | 60 ± 10 |
| Mean BMI | 32 ± 11 |
| Mean room time (minutes) | 376 ± 186 |
| Mean bypass time (minutes) | 96 ± 24 |
| Mean length of stay (index hospitalization) | 28 ± 25 days |
| 1-year survival rate post LVAD implant | 83% |
BMI = body mass index; LVAD = left ventricular assist device; NICM = nonischemic cardiomyopathy.
Survival
One patient died within 24 hours of ablation owing to pulmonary hemorrhage unrelated to the ablation procedure. Two patients died within 3 years of LVAD implantation: 1 died from complications owing to abdominal aortic aneurysm endoleak 2 years after LVAD; the other eventually declined further therapies and died at home.
The remaining 3 patients underwent transplant within 1 year of LVAD implant and remain alive today.
Recurrent ventricular arrhythmia
Post LVAD, 3 patients remained VA free and 3 patients had VA recurrence (1–91 days). Four out of 6 patients were on amiodarone preprocedurally, with 5 out of 6 on amiodarone postoperatively. The only patient who did not receive amiodarone at any point died within 24 hours of implantation.
Destination therapy LVAD patients remained on amiodarone indefinitely. Of the patients who received LVADs and went on to receive heart transplants, 2 continued a short course of amiodarone after LVAD implantation, which was discontinued prior to transplantation (3–6 months). One required amiodarone for 1 year after LVAD implantation and then 1 month after orthotopic heart transplant.
The first patient developed VT storm during their index hospitalization on postoperative day 1, requiring a stellate ganglion block. That patient remained on antiarrhythmics and had recurrent VA requiring hospitalization 1 year after surgery. The patient died owing to complications from abdominal aortic aneurysm endoleak 2 years after LVAD implant.
The second patient was hospitalized for HF 2 months after surgery, requiring intravenous inotropy, which precipitated VA and an appropriate implantable cardioverter-defibrillator (ICD) shock. That patient received heart transplant 11 months after LVAD implant and had no further VA events.
The last patient was successfully managed as an outpatient for an appropriate ICD shock 91 days after LVAD implantation. That patient died under unrelated circumstances 2 years after LVAD implant without any further VA events.
Postoperative course
Apart from the acute VT storm and respiratory failure patients, the other patients had standard LVAD postoperative courses. One patient had a hospitalization for gastrointestinal bleeding 33 days after implantation and there was 1 HF admission 2 months after implant. Two patients had no further hospitalizations until their transplants.
Conclusion
Analysis is limited by small sample size, but half of our patients receiving LVAD and concomitant VA ablation had no VA on follow-up. Operation time, length of stay, and other outcome measures do not appear different from standard values.
Overall arrhythmia burden was low. One patient had refractory arrhythmias for years after LVAD but ultimately did not die from VA. Overall, 4 out of 6 patients did not have significant VA burden (singular ICD shock either managed successfully outpatient; or inotrope-instigated event that did not recur).
Concomitant VA ablation may carry additional risk and there have been observations of LVAD thrombosis and postoperative bleeding after ablation.
6
,7
To further assess risks, benefits, and outcomes, this intervention should be investigated in a randomized controlled trial: we applaud the efforts of the PIVATAL investigators (NCT05034432).8
We suspect intraoperative VA ablation has the potential to prolong VA-free survival and decrease subsequent hospitalization in this patient population without adversely affecting postoperative care.Key Teaching Points
- •Concomitant surgical ventricular tachycardia (VT) ablation at the time of left ventricular assist device (LVAD) implantation is an area lacking in data, but still may be reasonable and feasible given the challenges of catheter ablation and the potential for future high-risk procedures.
- •Intraoperative mapping in the open chest and with the LVAD can be challenging: this sample did not undergo intraoperative mapping. Surgical ablation sites were based on 12-lead VT morphology and available echo, magnetic resonance imaging, and/or prior intracardiac mapping/ablation. Recommendations on ablation sites from the Electrophysiology team were then weighed intraoperatively based on anatomic considerations.
- •The upcoming PIVATAL trial (NCT05034432) will hopefully shed more light on this particular population as well as further detail the risk/benefit profile of the procedure in a randomized controlled trial.
References
- Incidence of cardiac implantable electronic device complications in patients with left ventricular assist devices.JACC Clin Electrophysiol. 2021; 7: 494-501
- Lessons learned from catheter ablation of ventricular arrhythmias in patients with a fully magnetically levitated left ventricular assist device.Clin Res Cardiol. 2022; 111: 574-582
- Catheter ablation of ventricular tachycardia in patients with a ventricular assist device: a systematic review of procedural characteristics and outcomes.JACC Clin Electrophysiol. 2019; 5: 39-51
- Characterization of ventricular tachycardia after left ventricular assist device implantation as destination therapy.JACC Clin Electrophysiol. 2017; 3: 1412-1424
- Open chest epicardial VT ablation after LVAD: ounce of prevention or pound of cure?.JACC Case Rep. 2021; 3: 1061-1063
- Concomitant surgical cryoablation for refractory ventricular tachycardia and left ventricular assist device placement: a dual remedy but a recipe for thrombosis”.J Cardiothorac Surg. 2016; 11: 53
- Device therapy and arrhythmia management in left ventricular assist device recipient. a scientific statement from the American Heart Association.Circulation. 2019; 139: e967-e989
- The PIVATAL Study - study of ventricular arrhythmia (VTA) ablation in left ventricular assist device (LVAD) patients (PIVATAL). clinicaltrials.gov. National Institutes of Health, n.d..
Article info
Publication history
Published online: January 31, 2023
Publication stage
In Press Journal Pre-ProofFootnotes
Funding Sources: This research did not receive any specific grant from funding agencies in public, commercial, or not-for-profit sectors. Disclosures: No relevant disclosures or conflicts of interest for all authors.
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© 2023 Heart Rhythm Society. Published by Elsevier Inc.
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