Ventricular Arrhythmia Ablation in High-Risk Patients with Advanced Heart Failure

Background
Radiofrequency-guided catheter ablation (RFCA) is an established therapy for ventricular arrhythmias (VA). In high-risk patients, hemodynamic support (HS) is often required to guide ablation. Data on the safety and outcome of RFCA of drug-refractory VA in advanced heart failure (HF) patients are scares.

Objective
The aim of this observational study was to compare the acute procedural success, complications, 24-month VA-recurrence rates and mortality in advanced HF patients to patients without advanced HF. Beyond that, the impact of HS on patients’ outcome was analyzed.

Methode
Data from consecutive HF patients undergoing VA ablation procedures between 2018-2024 were analyzed. Advanced HF patients cumulatively met the following criteria: left ventricular ejection fraction (LVEF) <30%, New York Heart Association (NYHA) functional classes ≥ III, elevated NT-proBNP-levels >1.500pg/ml (group 1). These patients were compared to HF patients with a LVEF >30%, NYHA classes <III and NT-proBNP-level <1.500pg/ml (group 2). HS was defined as the use of an Impella, an extracorporeal membrane oxygenation (ECMO) or a left ventricular assist device (LVAD) in patients with (group 3) or without (group 4) advanced HF. All patients were continuously followed up in our outpatient clinic.

Results
A total of 187 consecutive HF patients (mean age 61.5±10.9 years, 13% female) were included. 62 advanced HF patients (group 1) (33%, mean age 63.5±8.9 years, 11% female) were compared to 57 patients without advanced HF (group 2) (31%, mean age 60.3±13.8 years, 12% female. HS was required in an additional 68 patients (36%, mean age 60.8 ± 9.8 years, 16% female). 92% of  them (n=62) suffered from advanced HF (group 3). Procedural data did not differ between the groups except for fluoroscopy times, which were significantly longer in the HS cohort of patients (group 3 and 4) (no HS:07:52±02:50 vs. HS:10:22 ± 07:04min; p=0.019). Acute procedural success (advanced HF: n=59, 95% vs. no advanced HF: n=57, 100%, p=0.245; no HS: n=116, 97% vs. HS: n=65, 96%, p=0.669) and major procedure complications (advanced HF: n=1, 2% vs no advanced HF: n=4, 7%, p=0.177; no HS: n=5, 4% vs. HS: n=4, 6%, p=0.7256) were comparable between the groups. Within the observation period 86 patients (46%) developed VA-recurrence and 37 patients (20%) died. 24-month VA-free survival (Log-rank p=0.344) and mortality (Log-rank p=0.256) was comparable between patients with advanced HF (group 1) and those without (group 2). In patients requiring HS (group 3 and 4), Kaplan-Meier-plot analyses revealed significantly higher estimated two-year VA-recurrence and mortality rates (Log-rank p=0.001) (group 1 and 2)  (Figure 1). Multivariate analyses confirmed HS as an independent predictor for VA-recurrence (Hazard ratio (HR) 2.404, Confidence Interval (CI) 1.504-3.842, p<0.001) and mortality (HR 3.392, CI 1.584-7.260, p=0.002).

Conclusion
In the specific cohort of advanced HF patients VA ablation procedures seem to be safe and effective with comparable acute and long-term success rates and complications. However, the need for HS was associated with an increased VA-recurrence and mortality rate.

Figure 1 

Kaplan-Meier-plot on A) VA-free-survival and b) mortality during the observation period of 24 months; HF, heart failure; EF, ejection fraction; VA, ventricular arrhythmia; HS, hemodynamic support; a p-value ≤ 0.05 and * indicate statistical significance.