Mapping of scar-related ventricular tachycardia (VT) in structural heart disease is
fundamentally driven by identifying the critical isthmus of conduction that supports
re-entry in and around myocardial scar. Mapping can be performed using activation
and entrainment techniques during VT, or by substrate mapping performed in stable
sinus or paced rhythm. Activation and entrainment mapping requires the patient to
be in continuous VT, which may not be haemodynamically tolerated, or, if tolerated,
may lead to adverse sequelae related to impaired end organ perfusion. Mechanical circulatory
support (MCS) devices may facilitate haemodynamic stability and preserve end organ
perfusion during sustained VT to permit mapping for long periods. Available options
for haemodynamic support include an intra-aortic balloon pump (IABP), TandemHeart
left atrial to femoral artery bypass system (CardiacAssist Inc., Pittsburgh, PA, USA),
Impella left ventricle (LV) to aorta flow-assist system (Abiomed, Danvers, MA, USA),
and extracorporeal membrane oxygenation (ECMO); the bypass and assist devices provide
far better augmentation of cardiac output than IABP. MCS has potential key advantages
including maintenance of vital organ perfusion, reduction of intra-cardiac filling
pressures, reduction of LV volumes, wall stress, and myocardial consumption of oxygen,
and improvement of coronary perfusion during prolonged periods of VT induction and/or
mapping. Observational studies show MCS allows for longer duration of mapping, and
increased likelihood of VT termination, without an increased risk of peri-procedural
mortality or VT recurrence in follow-up, despite being used in a significantly sicker
cohort of patients. However, MCS has increased risk of complications related to vascular
access, bleeding, thromboembolic risk, mapping system interference, increase procedural
complexity and increased cost. Acute haemodynamic decompensation occurs in ∼11% of
patients undergoing VT ablation, and is associated with increased mortality. Prospectively
identifying patients at risk of acute haemodynamic decompensation in the peri-procedural
period may allow prophylactic MCS. Although observational studies of MCS in patients
at high risk of haemodynamic decompensation are encouraging, its benefit needs to
be proven in randomised trials. This review will summarise the indication for MCS,
forms of MCS, procedural outcomes, complications and utility of MCS during VT ablation.
Keywords
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References
- Irrigated radiofrequency catheter ablation guided by electroanatomic mapping for recurrent ventricular tachycardia after myocardial infarction the multicenter thermocool ventricular tachycardia ablation trial.Circulation. 2008; 118: 2773-2782
- Prognostic importance of defibrillator shocks in patients with heart failure.N Engl J Med. 2008; 359: 1009-1017
- Association of antitachycardia pacing or shocks with survival in 69,000 patients with an implantable defibrillator.J Cardiovasc Electrophysiol. 2017; 28: 416-422
- 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.Heart Rhythm. 2018; 10 (Epub 2017 Oct 30): e190-e252https://doi.org/10.1016/j.hrthm.2017.10.035
- Comparative effectiveness of antiarrhythmic drugs and catheter ablation for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators: a systematic review and meta-analysis of randomized controlled trials.Heart Rhythm. 2016; 13: 1552-1559
- Long-term outcomes after catheter ablation of ventricular tachycardia in patients with and without structural heart disease.Heart Rhythm. 2016; 13: 1957-1963
- Cost effectiveness of ventricular tachycardia ablation versus escalation of antiarrhythmic drug therapy: the VANISH trial.JACC Clin Electrophysiol. 2018; 4: 660-668
- Quality of life with ablation or medical therapy for ventricular arrhythmias: a substudy of VANISH.J Cardiovasc Electrophysiol. 2018;
- Impact of ventricular tachycardia ablation on health care utilization.Heart Rhythm. 2018; 15: 355-362
- Long-term success of irrigated radiofrequency catheter ablation of sustained ventricular tachycardia: post-approval THERMOCOOL VT trial.J Am Coll Cardiol. 2016; 67: 674-683
- Venturing into ventricular arrhythmia storm: a systematic review and meta-analysis.Eur Heart J. 2013; 34: 560-571
- Catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-defibrillators: short-and long-term outcomes in a prospective single-center study.Circulation. 2008; 117: 462-469
- Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation of hemodynamically unstable ventricular tachycardia.J Am Coll Cardiol. 2010; 55: 2355-2365
- Can ventricular tachycardia non-inducibility after ablation predict reduced ventricular tachycardia recurrence and mortality in patients with non-ischemic cardiomyopathy? A meta-analysis of twenty-four observational studies.Int J Cardiol. 2016; 222: 689-695
- Substrate-based ablation versus ablation guided by activation and entrainment mapping for ventricular tachycardia: a systematic review and meta-analysis.J Cardiovasc Electrophysiol. 2016; 27: 1437-1447
- Catheter ablation in patients with multiple and unstable ventricular tachycardias after myocardial infarction: short ablation lines guided by reentry circuit isthmuses and sinus rhythm mapping.Circulation. 2001; 104: 664-669
- Outcomes of pre-emptive and rescue use of percutaneous left ventricular assist device in patients with structural heart disease undergoing catheter ablation of ventricular tachycardia.J Interv Card Electrophysiol. 2017; 48: 27-34
- Hemodynamic support in ventricular tachycardia ablation: an international VT ablation center collaborative group study.JACC Clin Electrophysiol. 2017; 3: 1534-1543
- Hemodynamic support for ventricular tachycardia ablation.Card Electrophysiol Clin. 2017; 9: 141-152
- Early mortality after catheter ablation of ventricular tachycardia in patients with structural heart disease.J Am Coll Cardiol. 2017; 69: 2105-2115
- Acute hemodynamic decompensation during catheter ablation of scar-related ventricular tachycardia: incidence, predictors, and impact on mortality.Circ Arrhythm Electrophysiol. 2015; 8: 68-75
- Activation and entrainment mapping of hemodynamically unstable ventricular tachycardia using a percutaneous left ventricular assist device.J Am Coll Cardiol. 2011; 58: 1363-1371
- Outcomes of rescue cardiopulmonary support for periprocedural acute hemodynamic decompensation in patients undergoing catheter ablation of electrical storm.Heart Rhythm. 2018; 15: 75-80
- Temporary mechanical circulatory support: a review of the options, indications, and outcomes.Clin Med Insights Cardiol. 2014; 8: 75-85
- The role of percutaneous left ventricular assist devices during ventricular tachycardia ablation.Europace. 2012; 14: ii26-ii32
- Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support.Circulation. 2011; 123: 533-543
- Mechanical circulatory support devices for acute right ventricular failure.Circulation. 2017; 136: 314-326
- Procedural and clinical outcomes after catheter ablation of unstable ventricular tachycardia supported by a percutaneous left ventricular assist device.Heart Rhythm. 2014; 11: 1122-1130
- Mexiletine or catheter ablation after amiodarone failure in the VANISH trial.J Cardiovasc Electrophysiol. 2018;
- Percutaneous endocardial and epicardial ablation of hypotensive ventricular tachycardia with percutaneous left ventricular assist in the electrophysiology laboratory.J Cardiovasc Electrophysiol. 2007; 18: 106-109
- Outcomes of ventricular tachycardia ablation using percutaneous left ventricular assist devices.Circ Arrhythm Electrophysiol. 2017; 10
- Outcomes of catheter ablation of ventricular tachycardia with mechanical hemodynamic support: an analysis of the medicare database.J Cardiovasc Electrophysiol. 2017; 28: 1295-1302
- Outcomes with prophylactic use of percutaneous left ventricular assist devices in high-risk patients undergoing catheter ablation of scar-related ventricular tachycardia: a propensity-matched analysis.Heart Rhythm. 2018;
- Percutaneous hemodynamic support with Impella 2.5 during scar-related ventricular tachycardia ablation (PERMIT 1).Circ Arrhythm Electrophysiol. 2013; 6: 151-159
- Percutaneous left ventricular assist devices in ventricular tachycardia ablation: multicenter experience.Circ Arrhythm Electrophysiol. 2014; 7: 244-250
- Outcomes of catheter ablation of ventricular tachycardia with mechanical hemodynamic support: an analysis of the medicare database.J Cardiovasc Electrophysiol. 2017; 28: 1295-1302
- Efficacy and safety of ventricular tachycardia ablation with mechanical circulatory support compared with substrate-based ablation techniques.Europace. 2012; 14: 709-714
- Catheter ablation of hemodynamically unstable ventricular tachycardia with mechanical circulatory support.Int J Cardiol. 2013; 168: 3859-3865
- Extracorporeal membrane oxygenation for hemodynamic support of ventricular tachycardia ablation.Circ Arrhythm Electrophysiol. 2016; 9
- Management of ventricular tachycardia in the setting of a dedicated unit for the treatment of complex ventricular arrhythmias: long-term outcome after ablation.Circulation. 2013; 127: 1359-1368
- Management of ventricular arrhythmias in patients with advanced heart failure.J Am Coll Cardiol. 2017; 69: 1842-1860
Article info
Publication history
Published online: October 16, 2018
Identification
Copyright
Crown Copyright © 2018 Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.
