Abstract
Introduction: Ambulatory inotropic therapy (AIT) is used in advanced heart failure as a bridge to advanced therapies or palliation. Inotropes are known arrhythmogenic agents. The characteristics, predictors and outcomes of ventricular tachycardia (VT) and ventricular fibrillation (VF) in this population are not well studied. Methods: This is a retrospective analysis of patients discharged on AIT. Patients were followed from AIT initiation until transplant, ventricular assist device placement, death, or wean from inotropes. Those without an ICD were excluded. All data was obtained through chart review. Results: We included 160 patients (mean age 60±13 years; 70% male). Milrinone was the selected inotrope in 94%. VT/VF occurred in 37/160 (23%) a median 2.6 months after AIT initiation. 20/37 (54%) had a VT/VF event within 3 months. 25/160 (16%) received ICD shocks and 40/160 (25%) received anti-tachycardia pacing (ATP). Inappropriate shocks for atrial arrhythmias occurred in 5 (3.1%). Of 59 episodes with available interrogation data, 70% were VT and 30% were VF. ATP successfully resolved 18/59 (14%), shocks were used in 33/59 (56%), and 8/59 (14%) resolved without device therapy. The mean VT cycle length was 284±63 ms with an average VT/VF time of 44±99 seconds. In univariate analysis previous VT/VF was predictive of VT/VF on AIT (HR: 2.54; 95% CI 1.33-5.86; p=0.01). Beta blocker therapy was protective (HR: 0.45; 95% CI 0.21-0.99; p=.05). Those patients with a VT/VF event in the first 3 months of AIT have higher 1 year mortality (80.4% vs 87.7%, p=0.02, Fig. 1). Prior to AIT initiation, VT/VF had occurred in 52 (33%) patients. Of the 108 patients with no history of VT/VF prior to AIT initiation, 19 (18%) had a de novo episode of VT/VF. Conclusions: Patients on AIT are at risk of ventricular arrhythmias. Those with previous VT/VF are at increased risk, but 15-20% with no previous events will have VT/VF. VT/VF within 3 months of AIT initiation may worsen prognosis and increase mortality.
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