Ventricular Tachycardia in Patients with an - Biosense Webster LVAD - - PDF document

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Disclosures Consulting and honoraria: - Abbott Ventricular Tachycardia in Patients with an - Biosense Webster LVAD Is There a Role for Prophylactic Ablation? - Boston Scientific Joshua D. Moss, MD, FACC, FHRS Associate Professor of

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Joshua D. Moss, MD, FACC, FHRS Associate Professor of Clinical Medicine Cardiac Electrophysiology University of California San Francisco @JDMossMD (#CHRS2019)

Ventricular Tachycardia in Patients with an LVAD – Is There a Role for Prophylactic Ablation?

Disclosures

Consulting and honoraria:

Abbott
Biosense Webster
Boston Scientific

“I just feel a little funny”

Do ventricular arrhythmias even matter after LVAD?

“I just feel a little funny”

Do these ventricular arrhythmias even matter after LVAD?

Ventricular Arrhythmias as Adjudicated Cause of Death over 2 years follow-up:

Centrifugal flow pump – 2 of 98
Axial flow pump – 1 of 103

Cancer: 2 centrifugal — 0 axial Driveline/power/battery issues: 6 centrifugal — 2 axial

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Garan AR et al. J Heart Lung Transplant 2015; 34(12): 1611-6

Pain/trauma of ICD shocks
RV failure from VA (45% versus 23%

incidence early post-op) and from multiple ICD shocks Decreased CO and frequent need for RVAD, inhaled pulmonary vasodilators, inotropes

VAs post-LVAD are associated with higher morbidity and risk of death

Follow-up years Probability of Death No VT/VF VT/VF

No VT/VF 108 84 49 24 VT/VF 41 34 26 13 YorukA et al. Heart Rhythm 2016; 13(5): 1052-6 (And in MOMENTUM 3: RHF by far most common cause of death, in 57/1020)

VAs early post-LVAD portend a negative prognosis acutely

GalandV et al. JACC EP 2019; 5: 944-54

(Though overall risk of death with late VAs is less clear)

GalandV et al. Predictors and Clinical Impact of Late VAs in Patients with CF-LVADs. JACC: EP 2018; 4(9)

Late VAs No Late VAs Transplant (187/494) 32.2% 39.9% Death (151/494) 35.3% 28.8% Cardiovascular death 61.7% 33.7% LVAD thrombosis RV failure Electrical storm 31% 34% 24% 46% 37% 0% Non-CV death/unknown 38.3% 66.3%

(Transplant-free)

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101 2

But epicardial ablation after LVAD is a non-trivial challenge

Total 1. Ventricular arrhythmias after LVAD implant are bad 2. Accessing the epicardial surface after any cardiac surgery can be challenging – perhaps no more so than after LVAD 3. The ability to further risk stratify patients and identify areas for prophylactic ablation may improve post-operative outcomes

Premises for development of an intraoperative mapping technique: A risk score has been derived (but includes post-LVAD parameters)

GalandV et al. JACC: EP 2018; 4(9)

0-1: Low risk 2-4: Intermediate risk 5-6: High risk 7-10: Very high risk

Low risk Intermediate High Very high

Could intra-operative voltage mapping be another predictive tool?

Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192

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Ventral

Left Right Leg Front

Dorsal

Back Neck

Measured impedance variations are highly dependent on patch position

Posterior patch Anterior patch Start End

Measured impedance variations are highly dependent on patch position

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Posterior patch Anterior patch Start End

Measured impedance variations are highly dependent on patch position “Modified” patch placement dramatically improves map geometry Comparing patients with post-LVAD VA to those without

Few differences in:

Demographics
LVAD characteristics
Medical history
Medication use

Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192

No sustained VA after LVAD (n=11) Sustained VA after LVAD (n=4) P Ischemic cardiomyopathy Median EF at implant Sustained VA prior to LVAD ICD shocks prior to LVAD

Comparing patients with post-LVAD VA to those without

Few differences in:

Demographics
LVAD characteristics
Medical history
Medication use

No sustained VA after LVAD (n=11) Sustained VA after LVAD (n=4) P Ischemic cardiomyopathy 18% 75% 0.08 Median EF at implant 19% 13.5% 0.05 Sustained VA prior to LVAD 45% 100% 0.03 ICD shocks prior to LVAD 27% 100% 0.10

Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192

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Intra-op voltage mapping as a predictive tool

Survival free of VA or transplant

P = 0.003 15 patient cohort at 2 centers: Median 3034 points sampled Mean 11.9 minutes for sampling

38% of points >1.5 mV
26% of points < 0.5 mV
No post-implant VA
10% of points >1.5 mV
53% of points < 0.5 mV
Multiple post-implant VT

episodes and ICD shocks starting on POD #2 Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192 1.5 mV 0.5 mV

Median follow-up 311 days

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Conclusions

1. VAs post-LVAD don’t cause death directly, but they are associated with

RV failure, morbidity, and mortality

2. A consistent predictor of VAs post-LVAD has been pre-operative VA
3. Epicardial scar burden and characteristics may provide additional

predictive information

4. Intra-operative voltage mapping during LVAD implant can be done

safely, accurately, and quickly

5. While endocardial VTs can be safely targeted post-LVAD, the implant

procedure itself offers the last good epicardial exposure

6. Prospective evaluation of prophylactic, substrate-guided epicardial

ablation during LVAD implant is a logical next step @JDMossMD