Percutaneous Cardiac Support During Catheter Ablation Utilizing the Impella Microaxial Flow Pump
- Mon, 8/2/10 - 4:00pm
- 0 Comments
- 5431 reads
In this article, the authors provide an overview of their use of a microaxial flow pump in a patient with transposition of the great arteries (TGA). This device allowed hemodynamic stability during mapping and ablation of the atrial reentrant tachycardia.
Introduction
Transcatheter ablation of atrial flutter and ventricular tachycardia in patients with structural heart disease has proven effective in eliminating recurrent symptoms and frequent ICD discharges.1-3 However, hemodynamic instability may develop during arrhythmia mapping, particularly in patients with significant ventricular dysfunction.3
Several approaches have been utilized to achieve hemodynamic stability during ablation of unstable ventricular and atrial arrhythmias including the use of antiarrhythmic agents to slow the arrhythmia, single beat noncontact mapping, and substrate-based mapping approaches that do not require arrhythmia initiation.4,5 Hemodynamic stability may also be achieved during ablation of atrial arrhythmias by creating second degree atrioventricular block through pharmacologic manipulation. While substrate-based mapping and ablation can be successful, complete mapping of the clinical arrhythmia circuit, termination during ablation and noninducibility following ablation appear to be better predictors of long-term efficacy.5,6
Considerable progress has been made in the development of devices that provide hemodynamic support during cardiac interventions. Cardiopulmonary support using extracorporeal membrane oxygenation and percutaneous left ventricular assist devices have provided hemodynamic stability during cardiac catheterizations and arrhythmia ablations in pediatric and adult patients.7,8 The Impella device (Abiomed, Danvers, MA) is a microaxial flow pump that was developed as a percutaneous left ventricular assist device. The Impella LP 2.5 device is a catheter-based, miniaturized rotary blood pump that is inserted in the femoral artery and placed via a retrograde approach through the aortic valve into the left ventricle (Figure 1). The microaxial pump continuously aspirates blood from the left ventricle and pumps it into the ascending aorta with a maximal flow of 2.5 l/min.9 It has been used for hemodynamic support during high risk coronary interventions, as a bridge to recovery during fulminant acute myocarditis, and as treatment of cardiogenic shock caused by myocardial infarction.9-11 A modified version of the microaxial blood pump has been developed as a right ventricular assist device; however, this is not placed percutaneously, requiring direct cannulation of the right atrium and pulmonary artery.12
The Impella device can be placed percutaneously into the left ventricle during ventricular tachycardia ablation or into the systemic right ventricle during ablation of atrial flutter in adults with transposition of the great arteries (TGA) that are status post a Mustard or Senning operation.13
1. Stevenson WG, Soejima K. Catheter ablation for ventricular tachycardia. Circulation 2007;115:2750-2760. 2. Reddy VY, Reynolds MR, Neuzil P, et al. Prophylactic catheter ablation for the prevention of defibrillator therapy. N Eng J Med 2007;357:2657-2665. 3. Khairy P, Van Hare GF. Catheter ablation in transposition of the great arteries with Mustard or Senning baffles. Heart Rhythm 2009;6:283-289. 4. Della Bella P, Pappalardo A, Riva S, et al. Non-contact mapping to guide catheter ablation of untolerated ventricular tachycardia. Eur Heart J 2002;23:742-752. 5. Marchlinski FE, Zado E, Dixit S, et al. Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in setting of right ventricular cardiomyopathy. Circulation 2004;110:2293-2298. 6. Friedman PA, Asirvatham SJ, Grice S, et al. Noncontact mapping to guide ablation of right ventricular outflow tract tachycardia. J Am Coll Cardiol 2002;39:1808-1812. 7. Booth KL, Roth SJ, Perry SB, et al. Cardiac catheterization of patients supported by extracorporeal membrane oxygenation. J Am Coll Cardiol 2002;40:1681-1686. 8. Friedman PA, Munger TM, Torres M, Rihal C. 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. 9. Valgimigli M, Steendijk P, Sianos G, et al. Left ventricular unloading and concomitant total cardiac output increase by the use of percutaneous Impella Recover LP 2.5 assist device during high-risk coronary intervention. Catheter Cardiovasc Interv 2005;65:263-267. 10. Colombo T, Garatti A, Bruschi G, et al. First successful bridge to recovery with the Impella Recover 100 left ventricular assist device for fulminant acute myocarditis. Ital Heart J 2003;4:642-645. 11. Meyns B, Dens J, Sergeant P, et al. Initial experience with the Impella device in patients with cardiogenic shock – Impella support for cardiogenic shock. Thorac Cardiovasc Surg 2003:51:312-317. 12. Christiansen S, Brose S, Demircan L, Autschbach R. A new right ventricular assist device for right ventricular support. Eur J Cardiothoracic Surg 2003;24:834-836. 13. Fishberger SB, Asnes JD, Rollinson NL, Cleman MW. Percutaneous right ventricular support during catheter ablation of intra-atrial reentrant tachycardia in an adult with a mustard baffle-A novel use of the Impella device. J Interv Card Electrophysiol 2010 Apr 13. 14. Abuissa H, Roshan J, Lim B, Asirvatham SJ. Use of the Impella™ microaxial blood pump for ablation of hemodynamically unstable ventricular tachycardia. J Cardiovasc Electrophysiol 2009;21:458-461. 15. Perry JC, Boramanand NK, Ing FF. “Transseptal” technique through atrial baffles for 3-dimensional mapping and ablation of atrial tachycardia in patients with d-transposition of the great arteries. J Interv Card Electrophysiol 2003;9:365-369.
Post new comment