Management of VT in Advanced Heart Failure

Santangeli P, Rame JE, Birati EY, Marchlinski FE.
Management of Ventricular Arrhythmias in Patients With Advanced Heart Failure. J Am Coll Cardiol 2017;69:1842-1860.

The following are 10 points to remember from this article on the management of ventricular arrhythmias in patients with advanced heart failure (A-HF):

  1. Ventricular arrhythmias (VAs) occur in up to one third of patients with A-HF; higher New York Heart Association (NYHA) class and decreased renal function are associated with appropriate implantable cardioverter-defibrillator (ICD) shocks.
  2. The volume and distribution of scar, as seen on contrast-enhanced cardiac magnetic resonance (CMR), are associated with sustained ventricular arrhythmias. Maladaptive hypertrophy, myocardial remodeling, and “engine-out-of-fuel metabolic substrate” contribute to the generation and maintenance of VAs.
  3. Pooled analysis of eight clinical trials has shown that there was a 34% reduction in recurrent VAs in patients on antiarrhythmic therapy, a benefit driven primarily by amiodarone. Unfortunately, most antiarrhythmic agents have negative inotropic effects, with the possibility of worsening of HF.
  4. Catheter ablation is recommended in patients with sustained monomorphic ventricular tachycardia (VT) refractory to antiarrhythmic drugs, but available evidence does not show significant reduction in mortality in patients who undergo ablation. Ablation can also be performed in patients with polymorphic VT and ventricular fibrillation (VF) if their episodes are triggered by reproducible premature ventricular depolarizations.
  5. CMR is useful to define the location and extent of the arrhythmogenic substrate, at times informing the potential need for epicardial excess.
  6. There are eight predictors of the acute hemodynamic decompensation in the peri-ablation period: age, diabetes, ischemic cardiomyopathy, reduced left ventricular ejection fraction, chronic obstructive pulmonary disease, presentation in VT storm, NYHA class III and IV, and general anesthesia.
  7. There are observational data to support the use of intraprocedural invasive hemodynamic monitoring and early mechanical hemodynamic support.
  8. Most patients with A-HF have hemodynamically unstable arrhythmias, which are not suitable for detailed activation and entrainment mapping, and complementary approaches are employed: substrate mapping.
  9. Surgical cardiac sympathetic denervation may be beneficial in patients with refractory VT. Patients with intractable VAs in the setting of reduced left ventricular function should be considered for heart transplantation and durable mechanical assist devices.
  10. End-of-life discussions are appropriate for patients with multiple comorbidities, worsening HF symptoms, and end-organ perfusion. Patients may opt for palliative care or hospice following ICD deactivation.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant

Keywords: Amiodarone, Arrhythmias, Cardiac, Anti-Arrhythmia Agents, Cardiomyopathies, Catheter Ablation, Defibrillators, Implantable, Diabetes Mellitus, Heart Failure, Heart Transplantation, Hypertrophy, Magnetic Resonance Spectroscopy, Palliative Care, Pulmonary Disease, Chronic Obstructive, Stroke Volume, Tachycardia, Ventricular, Ventricular Fibrillation, Ventricular Function, Left, Ventricular Premature Complexes

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