Clinical Reviews: Electrophysiology and Ablation
Identifying Risk and Management of Acute Haemodynamic Decompensation During Catheter Ablation of Ventricular Tachycardia Daniele Muser, Simon A Castro, Jackson J Liang and Pasquale Santangeli Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, USA
Abstract Radiofrequency catheter ablation (CA) has an established role in the management of patients with structural heart disease presenting with recurrent ventricular tachycardia (VT). Due to the complex underlying substrate, high burden of comorbidities and concomitant heart failure (HF) status, these patients may be at higher risk of periprocedural complications. The prolonged low-output state related to VT induction and mapping, as well as the fluid overload due to irrigated CA and the use of general anaesthesia, may decompensate the HF status, leading to multiple-organ failure and increase in early post-procedural mortality. Proper identification of patients at high risk of periprocedural acute haemodynamic decompensation (AHD) has important implications in terms of procedural planning (i.e. prophylactic use of mechanical assistance devices) and pre-procedural management in order to optimise the HF status. In the present manuscript we focus on the clinical predictors of AHD and the strategies to improve pre-procedural risk stratification, as well as the evidence supporting the use of haemodynamic support during CA procedures.
Keywords Haemodynamic decompensation, ventricular tachycardia, catheter ablation, mechanical haemodynamic support Disclosure: The authors have no conflicts of interest to declare. Received: 29 May 2018 Accepted: 19 July 2018 Citation: Arrhythmia & Electrophysiology Review 2018;7(4):ePub: 29 September 2018. DOI: https://doi.org/10.15420/aer.2018.36.3 Correspondence: Pasquale Santangeli, Hospital of the University of Pennsylvania, 9 Founders Pavilion – Cardiology, 3400 Spruce St, Philadelphia, PA 19104, USA. E:
[email protected]
The role of catheter ablation (CA) in the management of ventricular tachycardia (VT) is becoming increasingly relevant, having repeatedly shown its superiority to medical therapy in reducing the arrhythmic burden, thus improving prognosis and quality of life in patients with structural heart disease presenting with VT.1–4 In such patients, recurrent VT and heart failure (HF) status are connected by a bidirectional link. Structural and functional changes related to advanced HF, such as progressive myocardial fibrosis, adrenergic hyperactivity, mechanical and electrical remodelling, and metabolic dysregulation, all contribute to the genesis and maintenance of VT, which may occur in up to 30 % of these patients.5 Moreover, indicators of advanced HF, such as very low ejection fraction and advanced New York Heart Association (NYHA) functional class, have been associated with an increased rate of periprocedural complications, VT recurrence and mortality in patients undergoing CA of VT.6–9 Ventricular arrhythmias (VAs) may worsen HF status, increasing mortality and hospitalisations.5,7 In this setting, pre-procedural risk stratification to identify high-risk patients can allow for preprocedural planning and optimisation of overall clinical status before the procedure, improving patient safety and post-procedural outcomes. We summarise the strategies currently available to predict the risk of AHD and the evidence supporting the use of HF optimisation tools during CA of VT.
Incidence and Predictors of Acute Haemodynamic Decompensation Acute haemodynamic decompensation during CA of VT has been defined by our group as sustained hypotension (i.e. systolic blood
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