Mechanical circulatory support device does not impact outcomes in high-risk VT ablation
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Key takeaways:
- High-risk patients getting catheter ablation for ventricular tachycardia did not benefit from a mechanical circulatory support device.
- It remains to be seen whether certain kinds of patients could benefit.
In high-risk patients undergoing ablation for ventricular tachycardia, use of a mechanical circulatory support device did not improve clinical outcomes, researchers reported at Heart Rhythm 2023.
In a single-center, retrospective study, the researchers compared 41 patients with advanced HF or other high-risk characteristics who underwent catheter ablation of scar-mediated ventricular tachycardia (VT) with planned use of a temporary left ventricular assist device (Impella 5.0 and 5.5, Abiomed) from 2018 to 2022 with 41 propensity-matched patients who had VT ablation without a temporary LVAD from 2010 to 2022.
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“VT ablation is a challenging procedure in many patients and is associated with high mortality and morbidity, particularly in patients with a lot of comorbidities and high risk,” Jakub Sroubek, MD, PhD, heart rhythm specialist in the Cardiac Electrophysiology and Pacing Section of the Tomsich Family Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, said during a press conference. “As a result, there has been a lot of interest in using hemodynamic support devices. We looked at the Impella 5.0 and 5.5, which are newer devices that provide nearly complete left-side hemodynamic support. They are inserted by the surgeon usually through the axillary artery the day before the VT ablation, and the patient is weaned off them as soon [after the procedure] as possible. They are able to fully support the left side of the circulation.”
Among the cohort, the mean age was 66 years and 91% were men.
The mean number of induced VTs was 2.73 in the mechanical circulatory support group and 1.45 in the control group (P = .032), and the mechanical circulatory support group had more mapped VT circuits (2 vs. 1; P < .001), more VTs terminated with ablation (1 vs. 0; P < .001) and fewer external shocks or antitachycardia pacing (26.8% vs. 61%; P = .004), according to the study, which was simultaneously published in the Journal of the American College of Cardiology.
“In that sense, [the device] provided a positive influence on the actual procedure,” Sroubek said.
The mechanical circulatory support group had more procedure-related complications than the control group (29.3% vs. 2.4%; P = .002) and three patients in the mechanical circulatory support group died from procedure-related complications, according to the researchers.
“It needs to be said that even though these were technically major complications requiring reoperations, most of these were hematomas at the site of the Impella implant, which is very frequent in these operations ... and to our knowledge does not have an effect on the clinical outcomes,” Sroubek said.
During a median follow-up of 467 days, the primary outcome of death, permanent LVAD implantation or heart transplantation occurred similarly in both groups (HR = 1.11; 95% CI, 0.61-2.03; P = .734), as did the key secondary endpoint of recurrent VT or ventricular fibrillation (subdistribution HR = 1.08; 95% CI, 0.63-1.85; P = .768), Sroubek said during the press conference.
In a prespecified subgroup analysis based on PAINESD score, which predicts acute hemodynamic decompensation and mortality, the results were consistent regardless of whether patients had a low or high score, he said.
“This does not automatically imply that the use of Impella should be avoided in all patients,” Sroubek said during the press conference. “There almost certainly are some niche populations that will benefit. All this study shows is that ... it perhaps does not warrant a broad application to all high-risk patients, and that patient selection is vital.”
Reference:
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Sroubek J, et al. Late Breaking Clinical Trials and Science – Innovations. Presented at: Heart Rhythm 2023; May 19-21, 2023; New Orleans (hybrid meeting).
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