Mechanical circulatory support during ventricular tachycardia ablation: Feasibility and safety in a real-world cohort
S Lengauer, M Telishevska, H Krafft, M Schwendt, M Al Fayad, F Bahlke, D Dischl, N Erhard, F Englert, T Reiter, M Tydeks, J Syvaeri, I Deisenhofer, G Hessling, M PopaAbstract
Background
Ventricular tachycardia (VT) ablation in patients with severely reduced ejection fraction is limited by hemodynamic instability. Temporary circulatory support systems might help to improve periprocedural hemodynamics.
Purpose
To assess feasibility, acute success and safety profile of a femoral microaxial pump (MAP) for circulatory support during complex VT ablation.
Methods
This retrospective single center study included n=26 consecutive high-risk patients with therapy-refractory hemodynamically non-tolerated VT that underwent n=31 VT ablations on MAP support. After obtaining large bore femoral access (14 French[F]) using ultrasound guidance, the MAP was advanced to the left ventricle (LV) and a flow rate of 3.1–3.4L/min was established. Electroanatomical activation mapping of inducible VT was performed with a multipolar catheter. VT ablation using radiofrequency (RF) energy was guided by critical isthmus, functional substrate mapping and late enhancement imaging of scar areas. At the end of the procedure, two plug-based (6F+8F) vascular closure devices (VCD) were used in 51.6%, a combination of plug- and suture-based VCD in 32.3% or two suture-based VCD in 12.9% of cases.
Results
Baseline and procedural characteristics are presented in Table 1. Many patients (61.5%) presented in electrical storm and 53.9% patients had undergone a mean of 2.5±1.7 unsuccessful prior ablations. MAP implantation was successful in all cases. Procedure duration was 219.0±66.0 min with on-pump time of 153.0±63.0 min (Fig. 1). VT was inducible in 71.0% procedures and activation mapping feasible in 50.0% of these cases. At the end of the procedure, clinical VT was non-inducible in all patients. MAP weaning was successful at the end of the procedure in 90.3%. Further monitoring on intensive care unit was required in 71.0% of cases for 3.3±2.9 days. In-hospital major adverse events occurred in 6%: One patient died and one experienced cardiogenic shock. Femoral access complications occurred as pseudoaneurysms (PSA) in 22.6% (n=4 with active bleeding, n=3 without bleeding). Active bleeding was managed with covered stent implantation (n=2), manual compression (n=1) and covered stent and thrombin (n=1). PSA was treated with thrombin injection (n=2) or manual compression (n=1). PSA rate was higher with two plug-based VCD (37.5%) vs. suture-based VCD (7.1%, p=0.064). Transient acute renal injury occurred in 16%. No major bleeding or thromboembolic event was observed.
Conclusion
The use of MAP is feasible and provides essential hemodynamic support during complex VT ablation in high-risk patients. It is associated with high acute procedural success and enables immediate post-procedure weaning. Optimization of vascular closure techniques is warranted to further reduce groin complications related to large bore vascular access.Table 1Figure 1