Impact of Hemodynamic Support on patients’ outcome following Ventricular Arrhythmia Ablation

Background
Radiofrequency-guided catheter ablation (RFCA) is an established treatment for ventricular arrhythmias (VA). In high-risk patients, hemodynamic support (HS) is often required to guide ablation. Data on the outcome of patients that had undergone RFCA of drug-refractory VA requiring various types of HS 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 patients that had undergone  RFCA of VA with different types of HS to those without.

Methods
Data from consecutive patients undergoing VA ablation procedures between 2018-2024 were analyzed. HS was defined as the use of an Impella, an extracorporeal membrane oxygenation (ECMO) or a left ventricular assist device (LVAD). All patients were continuously followed up in our outpatient clinic.

Results
A total of 187 consecutive patients (mean age 61.5±10.9 years, 13% female) were included. HS was required in 68 patients (36%, mean age 60.8 ± 9.8 years, 16% female). 20 ECMO patients (29%, mean age 59.4 ± 11.4 years, 25% female) were compared to 19 Impella (28%, mean age 61.1 ± 11.2 years, 11% female) and 29 LVAD patients (43%, mean age 61.1 ± 7.7 years, 14% female). Procedural data did not differ between the groups except for fluoroscopy times, which were significantly longer in the HS cohort of patients (no HS:06:56±05:35 vs. HS:10:06 ± 06:78min; p<0.001). Acute procedural success (no HS: n=116, 98% vs. HS: n=65, 96%, p=0.670) and major procedure complications (no HS: n=5, 4% vs. HS: n=4, 6%, p=0.726) were comparable between the groups. In-hospital mortality was significantly higher in patients with HS (no HS: n=1, 1% vs. HS: n=20, 29%, p<0.001). Within the observation period 54 patients (29%) developed VA-recurrence and 37 patients (20%) died. 24-month VA-free survival (Log-rank p<0.001) and mortality (Log-rank p<0.001) were significantly higher in patients requiring HS with an ECMO or an LVAD compared to those without HS. In the specific cohort of Impella patients, Kaplan-Meier-plot analyses revealed comparable two-year VA-recurrence (Log-rank p=0.314) and mortality rates (Log-rank p=0.427) to patients without HS (Figure 1). Multivariate analyses confirmed HS with an ECMO and LVAD - but not with an Impella - as predictive for VA-recurrence (Hazard ratio (HR) 3.655, Confidence Interval (CI) 1.732-7.715, p<0.001) and mortality (HR 3.947, CI 1.091-14.280, p=0.036).

Conclusion
In the specific cohort of patients requiring HS VA ablation procedures seem to be safe and effective with comparable acute success rates and complications. In contrast to HS with an ECMO or an LVAD, HS with an Impella was not associated with a significantly 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; HS, hemodynamic support, VA, ventricular arrhythmias;  p-value ≤0.05 indicates statistical significance.