1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland
Background:
Radiofrequency-guided catheter ablation is an established treatment option for ventricular arrhythmias (VA). Clinically unstable patients with incessant VA often require hemodynamic support (HS) to guide ablation. Real-world data on the clinical outcome of patients receiving HS during VA ablation procedures are scarce.Objective: The aim of this observational study was to analyze the acute procedural success as well as VA-recurrence rates and mortality in patients requiring HS during VA ablation procedures.
Methods: Data from consecutive patients receiving HS during VA ablation procedures between 2015-2023 were analyzed. HS was defined as the use of an Impella, an extracorporeal membrane oxygenation (ECMO) or a left ventricular assist device (LVAD). HS-group patients were compared to patients that underwent VA ablation procedures without HS. All patients were continuously followed up in our outpatient clinic. Data on procedural parameters, acute success and complications as well as VA-free survival and mortality were analyzed.
Results: A total of 95 consecutive patients (mean age 60.9±11.0 years, 15% female) were included. 62 patients (65%, mean age 60.4±9.4 years, 16% female) received HS (ECMO or Impella: n=26, 42%; ECMO+Impella: n=7, 11%; LVAD: n=29, 47%). Patients in the HS-cohort had a significantly lower left ventricular ejection fraction (LVEF) (p<0.001), a higher New York Heart Association (NYHA) functional class (p=0.013) and a more frequent antiarrhythmic drug use (p=0.045). Fluoroscopy times were significantly longer in the HS-group (HS: 10:22 ± 07:04 vs. no HS: 05:52 ± 02:50 minutes, p<0.001). Acute procedural success (HS: n=59, 95% vs. no HS: n=33, 100%, p=0.549) and major procedure complications (HS: n=4, 6% vs. no HS: n=4, 6%, p=1.000) were comparable between the two groups. Nevertheless, patients receiving HS had a significantly higher in-hospital mortality (HS: n=20, 32 % vs. no HS: n=2, 6%, p=0.004). Within the observational period of two-years 56 patients (59%) developed VA-recurrence. Importantly, 24-month-VA-free survival was comparable between the groups (p=0.114). But Kaplan-Meier-plot analyses revealed a significantly higher estimated two-year-mortality in patients who underwent an ablation with HS (Log-rank p=0.003) (Figure 1). Between the subgroups (ECMO or Impella vs. LVAD) no statistically relevant differences were observed (Log-rank p=0.465). Multivariate analyses revealed HS as an independent predictor for mortality (Hazard ratio (HR) 3.259, Confidence Interval (CI) 1.060-10.015, p=0.039), but not for VA-recurrence.
Conclusion: Protected VA ablation procedures using HS seem to be safe and effective with comparable acute and long-term success rates as well as complications. But the need for HS is associated with an increased the risk for mortality. Further studies are warranted to validate our initial observations.
Figure 1 Kaplan-Meier-plot on 24-month survival (mortality)
HS, hemodynamic support; ECMO, extracorporeal membrane oxygenation; LVAD, left ventricular assist device; a p-value ≤ 0.05 indicates statistical significance.