Ventricular Tachycardia Cryoablation During HeartMate 3™ Implantation: A Case Series

Abstract

Introduction Ventricular arrhythmias (VA) are common in ischemic cardiomyopathy (ICM) causing higher morbidity and mortality after left ventricular assist device (LVAD) implantation.1 While cardiac unloading can ameliorate ventricular tachycardia (VT), persistent post-implant VT results in RV failure and death. A 2013 study reported lower incidence of VA after cryoablation during HeartMate (HM) 2™ implantation, however the data for ablation with HM 3™ implants is slim.2 We present a single-center, 3-patient case series from 2019 to 2021 for concurrent VT cryoablation with HM 3™ implantation. Case Series Three patients with known ICM presented in VT storm and cardiogenic shock requiring inotropic support with or without temporary mechanical support (MCS) devices. Detailed patient characteristics and outcomes are shown in Table 1. Decision-making Given the low likelihood of recovery due to cardiogenic shock and refractory VT requiring temporary MCS and inotropes in transplant ineligible patients, the heart-team decided to pursue concurrent endocardial VT ablation with LVAD implantation. In all 3 cases, LV apical coring was undertaken followed by cryoablation of obvious endocardial scar and then epicardial ablation to isolate the LV apex. Intraoperative mapping was not performed. Outcomes All three patients underwent successful HM3™ implantation with surgical VT ablation. They continue to do well post-implant with no recurrence of VA and improvement in symptoms to NYHA functional class I or II. Conclusions Our case series demonstrates that concurrent VT ablation and HM 3™ LVAD implantation can be safely and effectively performed in end-stage ischemic cardiomyopathy patients with refractory VT. This strategy showed no further recurrence of arrhythmias postoperatively and drastic improvement in symptoms. Further large multicenter analysis should be conducted to explore this as a viable strategy for durable mechanical support.