Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common with a prevalence of 20-50% at one year after LVAD implantation. Arrhythmias predispose these patients to additional risk and are associated with considerable morbidity from recurrent implantable cardioverter-defibrillator shocks, progressive failure of the unsupported right ventricle, and herald an increased risk of mortality. Management of patients with arrhythmias and LVAD differs in many aspects from the general population heart failure patients. These include ruling out the reversible causes of arrhythmias that in LVAD patients may include mechanical irritation from the inflow cannula and suction events. For patients with symptomatic arrhythmias refractory to medical treatment, catheter ablation might be relevant. There are specific technical and procedural challenges perceived to be unique to LVAD-related ventricular tachycardia (VT) ablation such as vascular and LV access, signal filtering, catheter manoeuvrability within decompressed chambers, and electroanatomic mapping system interference. In some patients, the arrhythmogenic substrate might not be readily accessible by catheter ablation after LVAD implantation. In this regard, the peri-implantation period offers a unique opportunity to surgically address arrhythmogenic substrate and suppress future VT recurrences. This document aims to address specific aspects of the management of arrhythmias in LVAD patients focusing on anti-arrhythmic drug therapy and ablations.
- MeSH
- Anti-Arrhythmia Agents * therapeutic use MeSH
- Ventricular Function, Left MeSH
- Catheter Ablation * methods MeSH
- Tachycardia, Ventricular therapy surgery physiopathology MeSH
- Consensus MeSH
- Humans MeSH
- Heart-Assist Devices * MeSH
- Risk Factors MeSH
- Arrhythmias, Cardiac * therapy physiopathology diagnosis MeSH
- Heart Failure * therapy physiopathology MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Practice Guideline MeSH
- Geographicals
- Europe MeSH
AIM: To describe clinical characteristics, procedural details, specific challenges, and outcomes in patients with HeartMate3TM (HM3), a left ventricular assist device system with a magnetically levitated pump, undergoing ventricular tachycardia ablation (VTA). METHODS AND RESULTS: Data were collected from patients with an HM3 system who underwent VTA in seven tertiary centres. Data included baseline patient characteristics, procedural data, mortality, and arrhythmia-free survival. The study cohort included 19 patients with cardiomyopathy presenting with ventricular tachycardia (VT) (53% with VT storm). Ventricular tachycardias were induced in 89% of patients and a total of 41 VTs were observed. Severe electromagnetic interference was present on the surface electrocardiogram. Hence, VT localization required analysis of intra-cardiac signals or the use of filter in the 40-20 Hz range. The large house pump HM3 design obscured the cannula inflow and therefore multi imaging modalities were necessary to avoid catheter entrapment in the cannula. A total of 32 VTs were mapped and were successfully ablated (31% to the anterior wall, 38% to the septum and only 9% to the inflow cannula region). Non-inducibility of any VT was reached in 11 patients (58%). Over a follow-up of 429 (interquartile range 101-692) days, 5 (26%) patients underwent a redo VT ablation due to recurrent VTA and 2 (11%) patients died. CONCLUSIONS: Ventricular tachycardia ablation in patients with HM3 is feasible and safe when done in the appropriate setup. Long-term arrhythmia-free survival is acceptable but not well predicted by non-inducibility at the end of the procedure.
The therapy of terminal heart failure with left ventricular assist devices has become a standard in cardiac surgery. Yet the surgical implantation technique is not standardized and differs from center to center. Complications associated with left ventricular assist device (LVAD) inflow cannula placement are thrombosis, suction events, and flow disturbances. Within this in vitro study we aimed to investigate if the fixation technique of the sewing ring has an impact on the position of the inflow cannula. For this in vitro study the HeartMate III LVAD (Thoratec Corporation, Pleasanton, CA, USA) was used. In five sessions, two approaches were considered for coring of the ventricle for LVAD inflow cannula insertion: "sew-then-core" and "core-then-sew." In the "sew-then-core" technique, the sewing cuff is first affixed to the heart, usually with 8-16 interrupted pledgeted mattress sutures. Subsequently, a cylindrical knife is used to resect a cylindrical core of myocardium to permit cannula insertion. In the "core-then-sew" technique, the sequence is reversed such that the knife is used before the suture ring is affixed. When the "sew-then-core" technique is used, the mattress sutures may be placed with full-thickness bites that penetrate the endocardium (i.e., transmural stitching) or partial-thickness bites that do not penetrate the endocardium (i.e., epicardial stitching). When the "core-then-sew" technique is used, the suture is passed fully into the ventricular lumen and fed back through the cored hole, at which point the needle may be reinserted into the freshly cored myocardium such that it exits the epicardium (i.e., transmural stitching with back stitch) or not (i.e., transmural stitching without back stitch). These four different sewing ring fixation suturing techniques were tested by experienced surgeons to affix the sewing ring: transmural stitching, epicardial stitching, transmural stitching with back stitch, and transmural stitching without back stitch. The sewing ring was sewed onto a silicone dummy designed to simulate the left ventricle with standard 2-0 Ethibond sutures (Ethicon, Somerville, NY, USA). Afterward, the dummies were measured and documented via photography. In addition, porcine hearts were used to simulate the suturing techniques in a physiological setting. The setting of the inflow cannula is substantially influenced by the fixation method of the sewing ring. Epicardial stitching showed the best results with stable cannula fixation, minimal gap around the cannula and no contact between the sutures and sewing ring with blood. The method of transmural stitching without back stitch showed the worst results by creating the biggest epithelial gap between inflow cannula and tissue as well as proving the biggest surface for blood contact between sewing ring and sutures. In general, both "sew-then-core" techniques resulted in a greater degree of apposition between the cuff and epicardial tissue. Within the study we revealed that the surgical fixation of the sewing ring has a significant impact on the inflow cannula stability, position, and tissue apposition in LVAD implantation surgery. Epicardial stitching of the sewing ring provides the best results in order to prevent suction events as well as thrombosis formation.
- MeSH
- Models, Anatomic MeSH
- Ventricular Function, Left * MeSH
- Prosthesis Implantation methods MeSH
- Cardiac Surgical Procedures methods MeSH
- Catheters * MeSH
- Humans MeSH
- Models, Cardiovascular MeSH
- Models, Animal MeSH
- Heart-Assist Devices * MeSH
- Swine MeSH
- Prosthesis Design MeSH
- Suture Techniques * MeSH
- Heart Ventricles physiopathology surgery MeSH
- Heart Failure physiopathology therapy MeSH
- Animals MeSH
- Check Tag
- Humans MeSH
- Animals MeSH
- Publication type
- Journal Article MeSH
- Comparative Study MeSH
A patient with dilated cardiomyopathy and no history of thromboembolic events received a surgically implanted axial-flow left ventricular assist device. After implantation, transesophageal echocardiography revealed a giant thrombus on the lateral and anterior aspects of the left ventricle. The inflow cannula inserted through the apex of the left ventricle was not obstructed, and the device generated satisfactory blood flow. Laboratory screening for thrombophilia showed protein S deficiency, heterozygous factor V Leiden mutation, and heterozygous MTHFR C667T mutation. During the entire duration of circulatory support, no significant suction events were detected, and the patient was listed for heart transplantation. Ventricular assist device implantation can unmask previously undiagnosed thrombophilia; therefore, it should be necessary to identify thrombophilic patients before cardiac support implantation.
- MeSH
- Echocardiography, Doppler, Color MeSH
- Cardiomyopathy, Dilated complications physiopathology MeSH
- Echocardiography, Transesophageal MeSH
- Factor V genetics MeSH
- Fatal Outcome MeSH
- Ventricular Function, Left * MeSH
- Genetic Predisposition to Disease MeSH
- Genetic Testing methods MeSH
- Prosthesis-Related Infections etiology MeSH
- Middle Aged MeSH
- Humans MeSH
- Methylenetetrahydrofolate Reductase (NADPH2) genetics MeSH
- Mutation MeSH
- DNA Mutational Analysis MeSH
- Protein S Deficiency complications diagnosis genetics MeSH
- Heart Diseases blood etiology genetics ultrasonography MeSH
- Heart-Assist Devices adverse effects MeSH
- Predictive Value of Tests MeSH
- Prosthesis Design MeSH
- Echocardiography, Doppler, Pulsed MeSH
- Heart Failure etiology physiopathology therapy ultrasonography MeSH
- Stroke Volume MeSH
- Thrombophilia blood complications diagnosis genetics MeSH
- Thrombosis blood etiology genetics ultrasonography MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Publication type
- Journal Article MeSH
- Case Reports MeSH
Implantace mechanické podpory srdeční (MPS) je novou léčebnou možností pro pacienty s terminálním srdečním selháním, u kterých se používá jako přemostění kritického období do transplantace srdce. I přes hemodynamické a klinické zlepšení může dojít po zavedení MPS ke zvýšení frekvence komorových tachykardií. Uvádíme kazuistiku pacienta s neischemickou dilatační kardiomyopatií, u kterého se objevily po implantaci MPS (HeartMate II, Thoratec) četné symptomatické běhy komorových tachykardií. Při elektrofyziologickém vyšetření bylo zjištěno, že arytmie má fokální charakter a vychází z malé oblasti nízké voltáže přilehlé ke vtokové kanyle MPS. Aplikace radiofrekvenční energie v této oblasti vedla k úplnému vymizení komorové ektopie. Pacientovi byl implantován kardioverter-defibrilátor a po dobu sledování 12 měsíců nebyla dokumentována žádná recidiva komorové tachykardie. Recidivující monomorfní komorové tachykardie po implantaci MPS mohou vycházet z blízkosti vtokové kanyly a na jejich genezi se může podílet mechanické dráždění myokardu kanylou. Komorová ektopie může být úspěšně odstraněna pomocí katetrizační ablace.
Ventricular assist device (VAD) represents novel therapeutic option in patients with advanced heart failure. In this indication, VAD is used to bridge the time period to heart transplantation (bridge-to-transplant). Despite hemodynamic and clinical improvement, the implantation may be followed by an increase in frequency of ventricular tachycardias (VTs). We report a case of a patient with nonischemic dilated cardiomyopathy, who developed frequent symptomatic episodes of VTs after implantation of intracorporal VAD (HeartMate II, Thoratec). The arrhythmia had focal characteristics and electroanatomical mapping revealed that it originated from relatively small scar area adjacent to the inflow cannula. Radiofrequency catheter in this region successfully abolished VTs and no sustained arrhythmias were noted during the follow up of 12 months. Recurrent monomorphic VTs after implantation of left VAD may originate from the myocardium adjacent to the inflow cannula, which may facilitate bouts of ectopic activity by mechanical irritation. Such VT may be abolished successfully by catheter ablation.
- MeSH
- Defibrillators, Implantable MeSH
- Cardiomyopathy, Dilated surgery therapy MeSH
- Electrocardiography MeSH
- Financing, Organized MeSH
- Ventricular Function, Left MeSH
- Catheter Ablation methods MeSH
- Tachycardia, Ventricular etiology surgery MeSH
- Middle Aged MeSH
- Humans MeSH
- Heart-Assist Devices adverse effects MeSH
- Postoperative Complications MeSH
- Heart Failure complications MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Publication type
- Case Reports MeSH
