Percutaneous left ventricular assist devices during cardiogenic shock and high-risk percutaneous coronary interventions

Outcomes of pre-emptive and rescue use of percutaneous left ventricular assist device in patients with structural heart disease undergoing catheter ablation of ventricular tachycardia

PURPOSE

Patient selection and timing of percutaneous left ventricular assist device (pLVAD) insertion for maximal benefit during ventricular tachycardia (VT) ablation is not well defined. We aimed to assess the outcomes of pre-emptive and rescue use of pLVAD during VT ablation in patients with ischemic and non-ischemic cardiomyopathy.

METHODS

Between January 2009 and October 2011, 93 patients underwent VT ablation. Three groups were compared: (1) Rescue group (n = 12)-patients who required emergent pLVAD insertion due to hemodynamic collapse during VT ablation, (2) Pre-emptive group (n = 24)-patients who had pre-ablation pLVAD insertion, and (3) Non-pLVAD group (n = 57)-patients who did not undergo pLVAD insertion. Procedural outcomes including 30-day mortality were compared.

RESULTS

Thirty-day mortality was higher in the Rescue group compared to the Pre-emptive group (58 vs. 4 %, p = 0.003) and non-pLVAD (58 vs. 3 %, p = 0.001) group. There was no significant difference in 30-day mortality or long-term freedom of VT between the pre-emptive and non-pLVAD groups.

CONCLUSIONS

Despite rescue pLVAD insertion, hemodynamic collapse during VT ablation is associated with a persistently high 30-day mortality. Further studies are warranted to predict hemodynamic collapse and to refine the role of pLVAD in this setting.

Treatment of ventricular tachycardia in patients with heart failure

Heart failure is a major public health concern that is frequently complicated by ventricular arrhythmias. Sustained ventricular tachycardia is associated with an increased risk for progressive heart failure and sudden death. We summarize the current management strategies for ventricular tachycardia in heart failure patients, including implantable cardioverter-defibrillator therapy, pharmacologic therapy, catheter ablation techniques, ventricular assist device therapy, and heart transplantation.

Update on management strategies for separation from cardiopulmonary bypass

PURPOSE OF REVIEW

To update the reader about clinical management strategies for separation from cardiopulmonary bypass. A number of new drugs are being introduced in clinical practice, with significant utility in operative patient management. Further, there is increased routine use of complex devices to achieve separation from or avoidance of cardiopulmonary bypass.

RECENT FINDINGS

Selected medical and device strategies from the most recent literature will be discussed. First, the rationale for selected innovative agents to achieve myocardial performance is reviewed in four perioperative settings: agents for the management of myocardial dysfunction, vasomotor dysfunction, pulmonary hypertension, and right ventricular failure. Second is an evaluation of less commonly considered aspects of mechanical device use in the context of failure to wean from cardiopulmonary bypass or use to avoid cardiopulmonary bypass. Three devices will be discussed: intra-aortic balloon pump, ventricular assist devices, and extracorporeal membrane oxygenation.

SUMMARY

As our pharmacological and technological armamentarium improve, our population ages and procedures are attempted on patients with increasing co-morbid conditions, it will be important to both utilize newer pharmacological agents and consider innovative uses for device implementation to achieve optimal perioperative outcomes.