Intraoperative Ventricular Tachycardia Ablation During Left Ventricular Assist Device Implantation in High-Risk Heart Failure Patients
2022; Lippincott Williams & Wilkins; Volume: 15; Issue: 6 Linguagem: Inglês
10.1161/circep.121.010660
ISSN1941-3149
AutoresSinan Tankut, Igor Gošev, Ayhan Yoruk, Arwa Younis, Scott McNitt, Milica Bjelic, Himabindu Vidula, Isaac Wu, Mehmet K. Aktaş, Ilan Goldenberg, David T. Huang,
Tópico(s)Mechanical Circulatory Support Devices
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 15, No. 6Intraoperative Ventricular Tachycardia Ablation During Left Ventricular Assist Device Implantation in High-Risk Heart Failure Patients Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBIntraoperative Ventricular Tachycardia Ablation During Left Ventricular Assist Device Implantation in High-Risk Heart Failure Patients Sinan Tankut, MD, Igor Gosev, MD, PhD, Ayhan Yoruk, MD, MPH, Arwa Younis, MD, Scott McNitt, MSc, Milica Bjelic, MD, Himabindu Vidula, MD, Isaac Wu, MD, Mehmet K. Aktas, MD, MBA, Ilan Goldenberg, MD and David T. Huang, MD Sinan TankutSinan Tankut https://orcid.org/0000-0002-9317-5509 Department of Cardiology (S.T., H.V., M.K.A., D.T.H.), University of Rochester, NY. , Igor GosevIgor Gosev Clinical Cardiovascular Research Center (I.Goldenberg, S.M., M.B., I.G.), University of Rochester, NY. Department of Cardiac Surgery (I.Gosev), University of Rochester, NY. , Ayhan YorukAyhan Yoruk Department of Electrophysiology, University of California San Francisco (A.Y.). , Arwa YounisArwa Younis Department of Electrophysiology, University of California San Francisco (A.Y.). , Scott McNittScott McNitt https://orcid.org/0000-0001-5374-6322 Clinical Cardiovascular Research Center (I.Goldenberg, S.M., M.B., I.G.), University of Rochester, NY. , Milica BjelicMilica Bjelic https://orcid.org/0000-0003-0468-8511 Clinical Cardiovascular Research Center (I.Goldenberg, S.M., M.B., I.G.), University of Rochester, NY. , Himabindu VidulaHimabindu Vidula https://orcid.org/0000-0002-6169-4806 Department of Cardiology (S.T., H.V., M.K.A., D.T.H.), University of Rochester, NY. , Isaac WuIsaac Wu Department of Cardiac Anesthesia (I.W.), University of Rochester, NY. , Mehmet K. AktasMehmet K. Aktas https://orcid.org/0000-0002-9003-9384 Department of Cardiology (S.T., H.V., M.K.A., D.T.H.), University of Rochester, NY. , Ilan GoldenbergIlan Goldenberg https://orcid.org/0000-0002-5806-3325 Clinical Cardiovascular Research Center (I.Goldenberg, S.M., M.B., I.G.), University of Rochester, NY. and David T. HuangDavid T. Huang Correspondence to: David T. Huang, MD, Department of Cardiology, University of Rochester, 601 Elmwood Ave, Box 679, Rochester, NY 14642. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9165-7643 Department of Cardiology (S.T., H.V., M.K.A., D.T.H.), University of Rochester, NY. Originally published26 May 2022https://doi.org/10.1161/CIRCEP.121.010660Circulation: Arrhythmia and Electrophysiology. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 26, 2022: Ahead of Print We reported that preexisting ventricular tachyarrhythmia (VTA) is the most powerful predictor for developing VTA following left ventricular assist device (LVAD) implant.1,2 High VTA burden can lead to right heart failure, prolonged hospitalization, and increased mortality among LVAD recipients.2 Yet, the optimal management of VTA in these patients remains an area of ongoing research. We aimed to assess the VTA burden following intraoperative ablation during LVAD placement among high-risk heart failure patients.Ten patients underwent intraoperative VTA ablation during LVAD implantation between 2013 and 2019 at the University of Rochester Medical Center. All patients had an implantable cardioverter defibrillator and recurrent episodes of VTA necessitating implantable cardioverter defibrillator therapy despite antiarrhythmic drug therapy before LVAD implant. Decisions for concurrent VTA ablation during LVAD implantation were made by multidisciplinary consensus. Localization of VTA was best predicted using 12-lead ECG, echocardiography, and nuclear perfusion imaging. Implantable cardioverter defibrillator interrogation data were reviewed to determine the burden of postablation VTA events consisting of ventricular tachycardia (VT) and ventricular fibrillation. VTA burden, defined as the cumulative number of sustained or treated VT/ventricular fibrillation, pre-LVAD implantation was compared with VTA burden following intraoperative VTA ablation. The review of deidentified data from medical records without need for patient informed consent was approved by the Institutional Review Board. Requests to access the dataset may be sent to Clinical Cardiovascular Research Center at the University of Rochester.Among 10 study patients, mean age was 52±12 years and 3 were women. Five patients were diagnosed with ischemic cardiomyopathy, 7 with hypertension and 3 with diabetes. LVAD devices included HeartMate 2 (Abbott, Abbott Park, IL; n=4) and HeartMate 3 (n=6). Only one patient underwent prior VT catheter ablation. Three patients were on temporary mechanical support; 5 required inotropic support. All patients were on at least one antiarrhythmic drug before LVAD implantation. Eight patients had sustained VT/ventricular fibrillation requiring implantable cardioverter defibrillator therapies within 1 month before their LVAD surgery. Five patients underwent LVAD implant via minimally invasive thoracotomy approach. Intraoperative endocardial (n=5, 50%), epicardial (n=2, 20%), and both endocardial and epicardial (n=3, 30%) ablation was performed using radiofrequency or cryoablation. The aim of the ablation was to homogenize the substrate at the identified myocardial scar including predicted VTA isthmus and exit sites. Eight patients were on amiodarone therapy, 3 on mexiletine, and 7 on β-blocker 3 months post-LVAD implantation. Using negative binominal regression, the number of events per 10 patients per month prior versus post-LVAD implant was 17 versus 1.6, respectively (P<0.001). Comparison of VTA events 6 months pre-LVAD and post-LVAD implant and VTA ablation is demonstrated in Figure [A]. There was an early increase in VTA burden after LVAD implant which attenuated after (Figure [B]). During 6 months of follow-up, 3 (30%) patients died secondary to sepsis.Download figureDownload PowerPointFigure. Ventricular tachyarrhythmia burden in high-risk heart failure patients before and after ablation during left ventricular assist device (LVAD) implant surgery is illustrated. A, Comparison of ventricular tachyarrhythmia (VTA) events 6 mo pre-LVAD and post-LVAD implant and VTA ablation for all 10 patients. B, Mean cumulative VTA event per person after LVAD implantation.In this study, we assessed the VTA burden following intraoperative VT ablation at the time of LVAD implantation. We found that (1) in all patients the VTA burden significantly decreased after surgical VT ablation and (2) an increase in VTA events was observed early postimplant which significantly diminished after 5 months.Prior studies have demonstrated the safety of performing simultaneous VT ablation with LVAD implantation.3,4 Our study further supports the benefit of intraoperative ablation in select patients. We observed an increase in VTA events during the early postsurgical period that subsided significantly after 5 months. Early VTA events after LVAD implantations is common and seen up to 23% of patients within 1 month of surgery. Precipitating factors include use of inotropic medications, electrolyte abnormalities and fluid shifts, suction events, ischemia, and scar.5 Our series included high-risk heart failure patients with 30% of our patients on temporary mechanical circulatory support and half of the study population requiring inotropic therapy before LVAD implantation. Additionally, there were 3 deaths reported secondary to infectious causes within the first 6 months, which could have precipitated and contributed to experienced arrhythmic burden.Appropriate and accurate strategies to reduce early postimplant VTA are warranted. In our study, target for ablation was best predicted via 12-lead ECG, echocardiography, and nuclear imaging which is a limitation. The ablation targets can be enhanced by high-density voltage and pace mapping to further analyze the arrhythmogenic substrate and circuit. Kunkel et al4 demonstrated that surgical electroanatomic mapping is feasible and safe. The reduction in post-VTA ablation arrhythmic events may also be an effect from left ventricular unloading after LVAD implantation. Timing is, therefore, appropriate for a prospective investigation of perioperative VTA mapping and ablation to assess the potential in reducing postoperative VTA burden and improving outcome.Intraoperative VTA ablation during LVAD implantation can be effective among high-risk heart failure patients who present with a high VTA burden before LVAD placement. Additional studies are needed to identify the optimal intraoperative mapping modalities and ablation strategies for intraoperative VTA intervention during LVAD implantation.Article InformationSources of FundingNone.Nonstandard Abbreviations and AcronymsLVADleft ventricular assist deviceVTventricular tachycardiaVTAventricular tachyarrhythmiaDisclosures None.FootnotesFor Sources of Funding and Disclosures, see page 409.Correspondence to: David T. Huang, MD, Department of Cardiology, University of Rochester, 601 Elmwood Ave, Box 679, Rochester, NY 14642. Email [email protected]rochester.eduReferences1. Garan AR, Yuzefpolskaya M, Colombo PC, Morrow JP, Te-Frey R, Dano D, Takayama H, Naka Y, Garan H, Jorde UP, et al. Ventricular arrhythmias and implantable cardioverter defibrillator therapy in patients with continuous-flow left ventricular assist devices: need for primary prevention?J Am Coll Cardiol. 2013; 61:2542–2550. doi: 10.1016/j.jacc.2013.04.020CrossrefMedlineGoogle Scholar2. Yoruk A, Sherazi S, Massey HT, Kutyifa V, McNitt S, Hallinan W, Huang DT, Chen L, Aktas MK. Predictors and clinical relevance of ventricular tachyarrhythmias in ambulatory patients with a continuous flow left ventricular assist device.Heart Rhythm. 2016; 13:1052–1056. doi: 10.1016/j.hrthm.2016.01.033CrossrefMedlineGoogle Scholar3. Mulloy DP, Bhamidipati CM, Stone ML, Ailawadi G, Bergin JD, Mahapatra S, Kern JA. Cryoablation during left ventricular assist device implantation reduces postoperative ventricular tachyarrhythmias.J Thorac Cardiovasc Surg. 2013; 145:1207–1213. doi: 10.1016/j.jtcvs.2012.03.061CrossrefMedlineGoogle Scholar4. Kunkel M, Rothstein P, Sauer P, Zipse MM, Sandhu A, Tumolo AZ, Borne RT, Aleong RG, Cleveland JC, Fullerton D, et al. Open surgical ablation of ventricular tachycardia: Utility and feasibility of contemporary mapping and ablation tools.Heart Rhythm O2. 2021; 2:271–279. doi: 10.1016/j.hroo.2021.05.004CrossrefMedlineGoogle Scholar5. Garan AR, Levin AP, Topkara V, Thomas SS, Yuzefpolskaya M, Colombo PC, Takeda K, Takayama H, Naka Y, Whang W, et al. Early post – operative ventricular arrhythmias in patients with continuous- flow left ventricular assist devices.J Heart Lung Transplant. 2015; 34:1611–1616. doi: 10.1016/j.healun.2015.05.018.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails June 2022Vol 15, Issue 6 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.121.010660PMID: 35617273 Originally publishedMay 26, 2022 Keywordsmortalitycatheter ablationhospitalizationtachycardiaheart failurePDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-DefibrillatorHeart Failure
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