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

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 Clinical Medicine Cardiac Electrophysiology University of California San Francisco @JDMossMD (#CHRS2019) Do ventricular arrhythmias even matter after LVAD? Do these ventricular arrhythmias even matter after LVAD? “I just feel a “I just feel a little funny” little funny” 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 1 9/14/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

VAs post-LVAD are associated with higher morbidity and risk of death VAs early post-LVAD portend a negative prognosis acutely • Pain/trauma of ICD shocks • RV failure from VA (45% versus 23% Probability of Death incidence early post-op) and from multiple ICD shocks VT/VF Decreased CO and frequent No VT/VF need for RVAD, inhaled pulmonary vasodilators, inotropes Follow-up years No VT/VF 108 84 49 24 (And in MOMENTUM 3: RHF by far most VT/VF 41 34 26 13 common cause of death, in 57/1020) Garan AR et al. J Heart Lung Transplant 2015; 34(12): 1611-6 YorukA et al. Heart Rhythm 2016; 13(5): 1052-6 GalandV et al. JACC EP 2019; 5: 944-54 (Though overall risk of death with late VAs is less clear) Partner Logo Late VAs No Late VAs Transplant (187/494) 32.2% 39.9% (Transplant-free) Death (151/494) 35.3% 28.8% Cardiovascular death 61.7% 33.7% LVAD thrombosis 31% 46% RV failure 34% 37% Electrical storm 24% 0% Non-CV death/unknown 38.3% 66.3% 9/14/2019 GalandV et al. Predictors and Clinical Impact of Late VAs in Patients with CF-LVADs. JACC: EP 2018; 4(9) 2 9/14/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

But epicardial ablation after LVAD is a non-trivial challenge Premises for development of an intraoperative mapping technique: 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 Total 101 2 A risk score has been derived (but includes post-LVAD parameters) Could intra-operative voltage mapping be another predictive tool? Low risk Intermediate 0-1: Low risk High 2-4: Intermediate risk 5-6: High risk Very high 7-10: Very high risk GalandV et al. JACC: EP 2018; 4(9) Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192 3 9/14/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Ventral Dorsal Partner Logo Back Neck Right Left Front Leg 9/14/2019 Measured impedance variations are highly dependent on patch position Measured impedance variations are highly dependent on patch position Posterior patch Anterior patch Start End 4 9/14/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Measured impedance variations are highly dependent on patch position “Modified” patch placement dramatically improves map geometry Posterior patch Anterior patch Start End Comparing patients with post-LVAD VA to those without Comparing patients with post-LVAD VA to those without No sustained VA Sustained VA after No sustained VA Sustained VA after P P after LVAD (n=11) LVAD (n=4) after LVAD (n=11) LVAD (n=4) Ischemic Ischemic 18% 75% 0.08 cardiomyopathy cardiomyopathy Median EF at Median EF at 19% 13.5% 0.05 implant implant Sustained VA Sustained VA Few differences in: Few differences in: 45% 100% 0.03 prior to LVAD prior to LVAD • Demographics • Demographics ICD shocks prior ICD shocks prior 27% 100% 0.10 • LVAD characteristics • LVAD characteristics to LVAD to LVAD • Medical history • Medical history • Medication use • Medication use Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192 Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192 5 9/14/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Intra-op voltage mapping as a predictive tool Partner 15 patient cohort at 2 centers: Logo Median 3034 points sampled Mean 11.9 minutes for sampling Survival free of VA or transplant 1.5 mV 0.5 mV P = 0.003 • 10% of points >1.5 mV • 38% of points >1.5 mV • 53% of points < 0.5 mV • 26% of points < 0.5 mV • Multiple post-implant VT • No post-implant VA episodes and ICD shocks Median follow-up 311 days starting on POD #2 9/14/2019 Moss JD et al. J Cardiovasc Electrophys 2019; 30:183-192 Conclusions @JDMossMD 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 6 9/14/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]