Recurrent refractory ventricular tachycardia in a patient with LVAD
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1 Monster Cases Recurrent refractory ventricular tachycardia in a patient with LVAD Maurizio Lunati MD Director SC Cardiologia 3 Elettrofisiologia Chairman De Gasperis Cardio Center Department ASST G.O.M. Niguarda Cà Granda-Milano maurizio.lunati@ospedaleniguarda.it
2 Potential conflicts of interest Maurizio Lunati MD 2017 Declaration of Interest provided to the European Society of Cardiology Institutional research funding: Boston Scientific, Biotronik, Medtronic, St. Jude Medical/Abbott, Sorin/Livanova Speaker fees, Honoraria, Consultancy, Advisory Board fees, Investigator, Committee Member, etc. Bayer, Biotronik, Boehringer-Ingelheim, Boston Scientific, Medtronic, St. Jude Medical/Abbott, Sorin/Livanova,
3 Monster Case 1 Male 59 yrs, 182 cm x 85 kg March 2012: diagnosis of non-ischemic dilated cardiomyopathy (EF 25%, no evidence of CAD) -> medical therapy October 2012: EF 13% VO2max = 11.4 ml/kg/min Cardiac MRI: no edema, no infiltration, large areas of fybrosis October 2014: acute HF; EF 16%; optimization of medical therapy; single chamber ICD implant in PP Persistent NYHA Class IIIb January 2015: hospital readmission for evaluation of non conventional therapy ( LVAD vs Heart Transplant ) Pedretti/Lunati J. Arrhythmia 2017, 33, 494
4 Monster Case 2 I II III avr avl Hb Na K Creatinine Bilirubine GGT 14.0 g/dl 135 mmoli/l 4.28 mmoli/l 1.18 mg/dl 2.4 mg/dl 134 mg/dl avf V1 V2 V3 Colinesterasi Colesterolo T Proteine probnp 6871 U/L 146 mg/dl 6.1 g/dl 5752 ng/l V4 V5 V6
5 LV : DTD 67, VTD 234, IVS 7, PP 6, EF 22% Restrictive diastolic pattern Spontaneous echocontrast Monster Case 3
6 Functional MR 2+/4+. Monster Case 4
7 RV enlarged (41 x 48mm) TAPSE 13, s' 0.8 m/s, FAC 13% PAPs 48 mmhg (AcT 46 msec) Monster Case 5
8 Monster Case 6 Basal: FAC 13%, midportion strain = -13%. Dopamine 15 y/kg/min: FAC 36%, midportion strain = -21%
9 Monster Case 7 Right Heart catheterization Basal: RA 6, PAP 57/22/36, PCW 22, CO 3,75, CI 1,84, PVR 3,74, PVR-I 7,6 SNP 0,5 y/kg/m: RA 2, PAP 29/12/20, PCW 9, CO 3,92, CI 1,92, PVR 2,8, PVR-I 5,71 Pulmonary hypertension ( partially reversible )
10 Monster Case 8 January 2015: L-VAD HMII was implanted (BRIDGE to CANDIDANCY) From post-operative day 11 recurrent monomorphic NSVT and SVT occurred, triggered by ortostatism and Valsalva maneuvers Electrolytic imbalance, LVAD suction events, inflow cannula malposition were excluded Preload adaptation, LVAD rotation speed reduction, IV amiodarone and lidocaine failed to control the recurrences
11 Occurrence of VTs after LVAD? A Never B Very rare ( < 5 % ) C Rare ( < 10% ) D Frequent and early ( up to 35 % )
12 1) frequent VT occurrence after LVAD implantation 1
13 VT occurrence after LVAD implantation 2 2) early incidence J T. Shirazi et all. Ventricular arrhythmias in patients with implanted ventricular assist devices: a contemporary review. Europace (2013) 15, 11 17
14 VT occurrence after LVAD implantation 3 3) monomorphic VT N. Patients = 91 O. Ziv et all. Effects of left ventricular assist device therapy on ventricular arrhythmias. JACC 2005
15 Mecchanisns VT occurrence after LVAD implantation 4 Scar ( prior myocardial fibrois) 91% Mechanical contact 9% Apical scarring Sacher F et al. - Circ Arrhythm Electrophysiol, :
16 Monster Case 9 Telemetriy during orthostatism V1 III I avr
17 Monster Case 10 No evidence of LVAD suction effect
18 Monster Case 11 No evidence of LGE EP study SVP: no induction of VT
19 Consequences of VT in patients after LVAD implantation on the overall cardiac function A Right ventricular dysfunction ( which is common after implantation of a LVAD ) B C D Lower LVAD flows Thrombus formation Al of the above
20 Monster Case 12 A rescue EP procedure was set up with a multidisciplinary team of physicians, nurses and ancillary support staff with specialized training in the management of advanced heart failure, cardiac transplant, ICD and LVAD patients -3 EPs -1 Anestesthesiologist -1 Cardiac surgeon -1 ECHO specialist -1 ICD Field Engineer -1 3D mapping Engineer -1 LVAD Field Engineer -3 Nurses
21 Monster Case 13 Transeptal access TE echo CS catheter
22 ThermoCool SmarTouch Monster Case RAO
23 MECCANISMO Monster Case 15 LVAD contact Local potential Unipolar QS
24 Monster Case 16 MAPPA DI ATTIVAZIONE Centrifugal activation
25 Monster Case 17 STRATEGIA ABLATIVA RF pulse applications to all cannulaenodocardiun contact sites
26 Monster Case 18 After RFCA No inducibility of clinical VT No inducibility of other arrhythmias Aggressive PVS Induced suction During IPN infusion
27 Monster Case 19 Non VT recurrence for 2 weeks. On day 14 recurrence of NS-VT Episodes of VT/VF RFCA * VT Recurrence Patient activity
28 Monster Case 20 -> Planning of a second procedure -> HTx took place 5 weeks after first ablation
29 Monster Case 21 Pathology observations
30 Monster Case 22 Fibrosis and RFCA lesions
31 Monster Case 23 VA occur early and frequently after LVAD implantation Arrhythmogenesis mostly due to structural reentry In our case: -focal origin, subendocardial substrate tissue infammation RFCA is feasible and promising In our case: -long term efficacy probably affected by specific nature of the lesion, power dispersion, nevertheless determinant in rhythm stabilization Need of a specialized multidisciplinary team
32 Thanks 24
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