PO-05-039 PERIPROCEDURAL ACUTE HEMODYNAMIC DECOMPENSATION ASSOCIATED WITH SUBSTRATE-BASED ABLATION OF VENTRICULAR TACHYCARDIA IN PATIENTS WITH STRUCTURAL HEART DISEASE – RARE AND NONPREDICTABLE EVENT

Abstract

Patients with structural heart disease (SHD) and recurrent ventricular tachycardia (VT) are at considerable risk of periprocedural complications of radiofrequency (RF) catheter ablation including acute hemodynamic decompensation (AHD). The PAINESD score [sum of 5, 3, 6, 6, 3, 5, and 3 points for chronic obstructive pulmonary disease (COPD), age >60 years, ischemic cardiomyopathy (ICM), NYHA Class >2, LV ejection fraction (LVEF) <25%, electrical storm (ES), and diabetes mellitus (DM), respectively] was proposed to predict the risk of AHD, and identify the patients who may benefit from pre-emptive use of percutaneous left ventricular assist device (pVAD). The single-center, retrospective study investigated the incidence of AHD in large-volume, tertiary referral EP center and the predictive power of the PAINESD score. We included patients who had their first ablation for SHD-related VT between August 2006 and December 2020. The procedure was performed under conscious sedation except for patients who were on mechanical ventilation because of hemodynamical or electrical instability before the ablation. Substrate mapping/ablation was performed primarily during spontaneous rhythm or right-ventricular pacing. Activation and entrainment mapping were used rarely, only in well-tolerated VTs. The goal of ablation was to abolish all inducible VTs. AHD triggered by ablation procedure was defined as intra- or early post-procedural (<12 h) development of acute pulmonary oedema or refractory hypotension, requiring urgent intervention like inotropic agents and/or artificial ventilation and/or pVAD implant. The study cohort consisted of 1143 patients (age: 63±13 years, males: 87%, ICM: 67%, ES: 25%, NYHA Class: 2.1±1.0, LVEF: 34±13%, DM: 32%, COPD: 12%). Their PAINESD score was 11.4 ± 6.6 (median: 12, interquartile range: 6–17). The ablation procedure (total duration 187±78 min, RF time: 23±15 min) was complicated by AHD in 13/1143 = 1.1% patients and these adverse events were not predicted by PAINESD score (Figure). We observed a substantially lower rate (1.1%) of AHD than previously reported (up to 11%). These events did not accumulate in patients with upper-tercile PAINESD score in whom the highest AHD risk was reported (up to 24%). This observation may be explained by careful substrate-based ablation under conscious sedation that prevents prolonged low-output state related to repeated VT induction and mapping in general anesthesia.