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Acute Hemodynamic Decompensation During Catheter Ablation of Scar-Related VT: Incidence, Predictors and Impact on Mortality | Journal Scan
Study Questions:
What is the prevalence of acute hemodynamic decompensation (AHD) in patients undergoing catheter ablation of scar-related ventricular tachycardia (VT)?
Methods:
The study population consisted of 193 patients (mean age, 62 years; 88% male; mean ejection fraction, 35%) who were referred for catheter ablation of VT in the setting of structural heart disease. Almost all patients (91%) had either an implantable cardioverter-defibrillator (ICD) or a biventricular ICD. The procedure was performed under conscious sedation (preferred) or general anesthesia (GA). The primary endpoint was periprocedural AHD, defined as sustained hypotension despite treatment with vasoactive agents and/or requiring mechanical support, or procedure discontinuation.
Results:
Among the 193 patients, AHD occurred in 22 patients (11%). Mechanical support was necessary in 9 of the 22 (41%) patients, and the procedure was terminated prematurely in 17 patients (77%). Patients who experienced AHD tended to be older, had a higher prevalence of various comorbidities, ischemic heart disease, VT storm, more severe heart failure, and were more likely to have undergone the procedure under GA. Most instances of AHD did not occur in the context of sustained VT. GA was the only procedural variable associated with AHD. Mortality was significantly higher among patients who experienced AHD versus those who did not (50% vs. 11%, p < 0.001).
Conclusions:
The authors concluded that AHD occurs in about 10% of patients undergoing catheter ablation of scar-related VT, and is associated with increased risk of mortality.
Perspective:
Catheter ablation of scar-related VT has been shown to reduce ICD shocks and may be associated with improved outcomes, particularly in patients with VT storm. However, these are long and complex procedures, associated with risks such as hemodynamic instability. Hypotension, whatever the cause, may not be well-tolerated in these patients with advanced heart disease and multiple comorbidities. GA may be more likely to result in procedural hypotension and is best avoided if possible. Mechanical devices (balloon pump, assist devices, and others) are options for patients with recalcitrant hemodynamic instability during VT ablation.
Keywords: Anesthesia, General, Catheter Ablation, Cicatrix, Comorbidity, Conscious Sedation, Defibrillators, Implantable, Heart Failure, Heart-Assist Devices, Hemodynamics, Hypotension, Myocardial Ischemia, Tachycardia, Ventricular, Anesthesia, General, Catheter Ablation, Cicatrix, Comorbidity, Conscious Sedation, Defibrillators, Implantable, Defibrillators, Implantable, Heart Failure, Heart-Assist Devices, Hemodynamics, Hypotension, Tachycardia, Ventricular, Myocardial Ischemia
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