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Introduction
With the number of cardiac transplants plateaued at 2,200 each year due to limited organ availability, left ventricular assist devices (LVAD) offer short and long-term hemodynamic support in end-stage heart failure.1 The device and surgical implant technology has progressed over time from axial continuous flow pumps to, most recently, the HeartMate 3™ Left Ventricular Assist Device (Abbott), which is a pericardially implanted, fully magnetically levitated, centrifugal pump.2 Despite improving survival and quality of life in Stage D heart failure, there are considerable challenges involved in managing LVAD patients long term. From an electrophysiologist’s perspective, arrhythmias are a major concern, particularly ventricular tachycardia (VT) and fibrillation. This is especially true when arrhythmias become resistant to medical therapy. While post-LVAD ventricular arrhythmias (VA) might well be tolerated for a short period, recurrent and long-lasting arrhythmias can result in right ventricular (RV) failure (from arrhythmia itself or in a setting of multiple ICD shocks), recurrent hospitalizations, and overall reduced quality of life.3 Current evidence points to the safety and efficacy of catheter ablation of VT in LVAD patients with high burden of VA. Performing an ablation procedure on such patients requires meticulous planning and a multidisciplinary team approach including the electrophysiologist, anesthesiologist, and heart failure specialist. In the modern era, an important aspect of being an interventional electrophysiologist is to be cognizant of the progressive LVAD device technology as well as to address clinical and device-related issues unique to LVAD recipients. In this article, we present a case of medically refractory VT in a patient with a HeartMate 3 LVAD.
Case Description
A 56-year-old male with permanent atrial fibrillation, atrioventricular node ablation, biventricular implantable cardioverter-defibrillator (BiV-ICD) implant, ischemic cardiomyopathy, and Stage D congestive heart failure, was hospitalized with multiple ICD shocks for monomorphic and polymorphic VT. Four months prior to presentation, the patient had destination therapy LVAD implantation (HeartMate 3). Post-operative course was significant for multiple appropriate ICD shocks for recurrent polymorphic and monomorphic VT. In the 3 weeks preceding hospitalization, the patient had symptoms of exertional dyspnea, dizziness, and palpitations secondary to VT. He failed to improve despite decreasing LVAD pump speed from 5800 RPM to 5500 RPM, antiarrhythmic therapy (metoprolol and amiodarone), and he received multiple appropriate ICD shocks. Upon admission, he received IV amiodarone and lidocaine, but still had recurrent sustained VT. Thus, the decision was made to proceed with catheter ablation of VT.
Catheter Ablation of VT: Our Approach

Arrhythmia Induction and Mapping

Amiodarone was discontinued, and the patient was discharged home in stable condition. He did not have any further VT episodes at 4-month follow-up.
Discussion





We opted for a stepwise approach in this patient: 1) We characterized the substrate with voltage map; 2) We used a duo-decapolar catheter with 2x2 spacing to create a detailed map of the late potentials as well as an activation map of VT; and 3) We identified the mechanism and continuous diastolic activity correlating with reentry with successful ablation using an irrigated tip catheter.
Salient Features of the HeartMate 3 Left Ventricular Assist System:
- Textured blood-contacting surfaces encourage a tissue-to-blood interface, which potentially reduces complications;
- Full MagLev™ (magnetically-levitated) Flow technology allows the device’s rotor to be “suspended” by magnetic forces, preventing friction and wear and tear on the rotor, and reducing blood trauma through gentle blood handling;
- Artificial Pulse technology prevents the formation of zones of recirculation and stasis.19
Challenges to Performing VT Ablation with the HeartMate 3:
- We have found a high-frequency noise on surface ECG makes morphology discrimination challenging; noise seems to disappear with higher revolutions per minute (rpms) during the “pulse” delivery by the device every 2 seconds;
- Inflow cannula may limit mapping and ablation of arrhythmia originating around insertion;
- Retrograde approach may be challenging;
- Transseptal puncture into a decompressed smaller sized left atrium may pose higher risk of perforation;
- Fluoroscopic barriers: LVAD cannula and drive line, prior implanted leads, pacing catheters, and transseptal sheath;
- Inadequate power delivery on cannula adjacent target sites;
- Epicardial access is usually not feasible.10,12
Conclusion
VT ablation in patients with the LVAD is safe and feasible. However, there are some potential challenges for the operator with regard to procedure planning, patient optimizing strategies, or performing the ablation. Based on available data, catheter ablation should be offered to patients with VT/VF with multiple ICD shocks that do not respond to medical therapy. ICD therapies in these patients is known to increase morbidity. More data is needed regarding the role of pre-surgical MRI-based substrate characterization, preemptive ablation during LVAD implant, particularly at the cannula insertion site, and optimal device programming in patients with continuous flow devices.
Disclosures: Dr. Batul has no conflicts of interest to report regarding the content herein. Dr. Gopinathannair reports consultancy/honoraria with Abbott, Pfizer, and ZOLL Medical Corporation; he is also on the advisory board at HealthTrust PG.
References
- Nakhara S, Chien C, Gelow J, et al. Ventricular arrhythmias after left ventricular assist device. Circ Arrhythm Electrophysiol. 2013;6:648-654.
- Mehra MR, Naka Y, Uriel N, et al; MOMENTUM 3 Investigators. A fully magnetically levitated circulatory pump for advanced heart failure. N Engl J Med. 2017;376:440-450.
- Garan AR, Levin AP, Topkara V, et al. Early post-operative ventricular arrhythmias in patients with continuous-flow left ventricular assist devices. J Heart Lung Transplant. 2015;34:1611-1616.
- Makki N, Mesubi O, Steyers C, Olshansky B, Abraham WT. Meta-analysis of the relation of ventricular arrhythmias to all-cause mortality after implantation of a left ventricular assist device. Am J Cardiol. 2015;116:1385-1390.
- Garan AR, Yuzefpolskaya M, Colombo PC, et al. Ventricular arrhythmia 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.
- Effimova E, Fischer J, Bertagnolli L, et al. Predictors of ventricular arrhythmia after left ventricular assist device implantation: A large single-center observational study. Heart Rhythm. 2017;14:1812-1819.
- Ziv O, Dizon J, Thosani A, Naka Y, Magnano AR, Garan H. Effects of left ventricular assist device therapy on ventricular arrhythmias. J Am Coll Cardiol. 2005;45:1428-1434.
- Raash H, Jensen BC, Chang PP, et al. Epidemiology, management, and outcomes of sustained ventricular arrhythmias after continuous-flow left ventricular assist device implantation. Am Heart J. 2012;164:373-378.
- Cantillon DJ, Tarakji KG, Kumbhani DJ, Smedira NG, Starling RC, Wilkoff BL. Improved survival among ventricular assist device recipients with concomitant implantable cardioverter-defibrillator. Heart Rhythm. 2010;7:466-471.
- Sacher F, Reichlin T, Zado ES, et al. Characteristics of ventricular tachycardia ablation in patients with continuous flow left ventricular assist devices. Circ Arrhythm Electrophysiol. 2015;8:592-597.
- Harding JD, Piacentino V 3rd, Rothman S, Chambers S, Jessup M, Margulies KB. Prolonged repolarization after ventricular assist device support is associated with arrhythmias in humans with congestive heart failure. J Card Fail. 2005;11(3):227-232.
- Hottigoudar RU, Deam G, Slaughter MS, et al. Ventricular tachycardia ablation in patients with HeartMate II left ventricular assist devices: rhythm matters in the bionic age. J Innov Cardiac Rhythm Manag. 2011;2:537-547.
- Vakil K, Kazmirczak F, Sathnur N, et al. Implantable cardioverter-defibrillator use in patients with left ventricular assist devices: A systematic review and meta-analysis. JACC Heart Fail. 2016;4:772-779.
- Enriquez AD, Calenda B, Miller MA, Anyanwu AC, Pinney SP. The role of implantable cardioverter-defibrillators in patients with continuous flow left ventricular assist devices. Circ Arrhythm Electrophysiol. 2013;6(4):668-674.
- Snipelisky D, Reddy YN, Manocha K, et al. Effect of Ventricular Arrhythmia Ablation in Patients with Heart Mate II Left Ventricular Assist Devices: An Evaluation of Ablation Therapy. J Cardiovasc Electrophysiol. 2017;28:68-77.
- Moss JD, Flatley EE, Beaser AD, et al. Characterization of ventricular tachycardia after left ventricular assist device implantation as destination therapy. A single center experience. J Am Coll Cardiol EP. 2017. (Article in press)
- Garan AR, Iyer V, Whang W, et al. Catheter ablation for ventricular tachyarrhythmias in patients supported by continuous-flow left ventricular assist devices. ASAIO J. 2014;60:311-316.
- Higgins SL, Haghani K, Meyer D, Pless T. Minimizing magnetic interaction between an electroanatomic navigation system and left ventricular assist device. J Innov Cardiac Rhythm Manag. 2013;4:1440-1446.
- HeartMate 3™ Left Ventricular Assist System (LVAS) Fact Sheet. Abbott. Available online at http://bit.ly/2AUfRrk. Accessed December 18, 2017.
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