Management of Ventricular Arrhythmias in Patients with Ventricular Assist Devices Management of ...

18 Pages·2016·3.26 MB·English

Management of Ventricular
Management of Ventricular
Arrhythmias in Patients with
Arrhythmias in Patients with
Ventricular Assist Devices
Ventricular Assist Devices
Joshua D. Moss
Joshua D. Moss Division of Cardiology
Division of Cardiology
8/9/2016
8/9/2016
Disclosures: Questions to address:
Speaking/consulting fees •What are the clinical implications and predictors of ventricular
arrhythmias after continuous flow LVAD implant?
• Biosense Webster
•What happens to the ICD after LVAD implant –does the patient
• St. Jude Medical really need it?
• Boston Scientific •How safe and efficacious is mapping and ablation of VT after
LVAD implant?
• Medtronic
•What measures can be taken before or during LVAD implant to
• Biotronik prevent ventricular arrhythmias?
33 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs 44 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
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Continuous flow LVAD: HeartMate II HeartMate II implant
55 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs 66 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
HeartMate II implant Continuous flow LVAD: HeartWare HVAD
77 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs 88 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
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HeartWare HVAD implant Questions to address:
•What are the clinical implications and predictors of ventricular
arrhythmias after continuous flow LVAD implant?
•What happens to the ICD after LVAD implant –does the patient
really need it?
•How safe and efficacious is mapping and ablation of VT after
LVAD implant?
•What measures can be taken before or during LVAD implant to
prevent ventricular arrhythmias?
99 Ventricular Arrhythmias after LVAD 111000 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
Questions to address: Do these ventricular arrhythmias matter?
“I just feel a little funny”
•What are the clinical implications and predictors of ventricular
arrhythmias after continuous flow LVAD implant?
•What happens to the ICD after LVAD implant –does the patient
really need it?
•How safe and efficacious is mapping and ablation of VT after
LVAD implant?
•What measures can be taken before or during LVAD implant to
prevent ventricular arrhythmias?
111111 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
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VA post-LVAD is associated with higher morbidity “Stable” VT is not tolerated indefinitely
•Pain/trauma of ICD shocks
•RV failure 
- From VA: incidence of RV failure 45%in patients with early VA  BUN Cr AST ALT
(versus 23% without) in one cohort
- From shocks: multiple ICD shocks associated with dramatically 
higher incidence of acute RV failure, compared with ATP alone 
or single shock (50 v. 4%)
Frequent need for RVAD, inhaled pulmonary vasodilator, inotrope
GaranAR et al. J Heart Lung Transplant 2015; 34(12): 1611-6
111111333333 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss 111111444444 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss
VA post-LVAD is associated with more re- VA post-LVAD is associated with higher risk of death
admissions
1
Post‐VAD VA 0.8
h VT/VF
No Post‐VAD VA at
e
of D 0.6
bility  0.4
a
ob No VT/VF
Pr 0.2
0
0 1 2 3 4
Years (after 1stappropriate ICD therapy)
No VT/VF 61 31 16 7
1
RaaschH et al. Am Heart J 2012;164:373-8 VT/VF 0 8   11 5 2
GaranAR et al. J Heart Lung Transplant 2015; 34(12): 1611-6 BrenyoA et al. J Cardiovasc Electrophys 2011
11111115555555 MMMVeaaannnntaaarigggceeeummmlaeeer nnnAtttr rooohfffy VVVtheeemnnntttiarrriiisccc uuualllaaaftrrre AAAr rrrLrrrVhhhyyyAtttDhhhmmmiiiaaasss iiinnn PPPaaatttiiieeennntttsss wwwiiittthhh VVVAAADDDsss 1111166666 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
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VA post-LVAD is associated with higher risk of death VA post-LVAD is associated with higher risk of death
h h
at at
e e
D D
of  VT/VF of  VT/VF
bility  bility 
a a
b b
o o
Pr Pr
No VT/VF No VT/VF
Follow‐up years Follow‐up years
No VT/VF 108 84 49 24 No VT/VF 108 84 49 24
VT/VF 41 34 26 13 VT/VF 41 34 26 13
YorukA et al. Heart Rhythm 2016; 13(5): 1052-6 YorukA et al. Heart Rhythm 2016; 13(5): 1052-6
111111777777 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss 111111888888 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss
Possible precipitants of early post-op events (Columbia) Possible precipitants of early post-op events (Columbia)
Electrolyte Ischemia Ischemia
Suction
Inotrope
Events with no
clear precipitant:
None 79% occurred in
patients with a pre-
operative VA
GaranAR et al. J Heart Lung Transplant 2015; 34(12): 1611-6 GaranAR et al. J Heart Lung Transplant 2015; 34(12): 1611-6
11119999 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs 22220000 VMeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
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Pre-LVAD VT/VF predicts early post-op VA Role of meds? Less -blocker, more amiopost-LVAD
Ischemia 70 *P < 0.05
*
60
50
Pre-LVAD
40
pa7ctlE9eiev%anertn spot srcwe cwicutihiprtr hiate a dnpn oitrn :e - Prevalence 2300 * Post-LVAD
operative VA
10
0
Ventricular Beta-Blocker Amiodarone
Arrhythmias (Pre-LVAD v. discharge)
GaranAR et al. J Heart Lung Transplant 2015; 34(12): 1611-6
Moss JD et al. In preparation
22221111 VMeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs 22222222 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
Pre-LVAD VT/VF also predicts late post-op VA Pre-LVAD VT/VF also predicts late post-op VA
GaranAR et al. JACC 2013; 61(25): 2542-50 YorukA et al. Heart Rhythm 2016; 13(5): 1052-6
22223333 MVeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs 2222244444 VMeanntarigceumlaer nAtr rohfy Vthemntiarisc ualaftre Ar rLrVhyAtDhmias in Patients with VADs
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Questions to address: ICD sensing in the RV decreases after LVAD implant
•What are the clinical implications and predcitorsof ventricular 12 500
arrhythmias after continuous flow LVAD implant? mV10 480
8 P < 0.01
•What happens to the ICD after LVAD implant –does the patient 460
really need it? 6 O
440 hm
4 s
•HLVoAwD sa ifme palnadn te?fficacious is mapping and ablation of VT after J 2 Threshold (J) PP == 00..2401 420
0 400
Pre‐LVAD Post‐LVAD
•What measures can be taken before or during LVAD implant to
prevent ventricular arrhythmias?
•21% of patients had R-wave sensing <5 mV post-LVAD
Thomas IC…Moss JD et al. PACE2014; 37:464-72
222222555555 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss 222222666666 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss
ICD sensing in the RV decreases after LVAD implant Defibrillation threshold may increase
12 500 •Disruption of ICD lead
mV10 480
8 P < 0.01 •Re‐orientation of heart relative to shock vector
460
6 O •Amiodarone use
440 hm
4 s
J 2 Threshold (J) PP == 00..2401 420 •Shunting of energy away from myocardium*
0 400 •Natural history of end‐stage cardiomyopathy?
Pre‐LVAD Post‐LVAD
222222777777 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss 222222888888 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss
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Potential remedies for high DFT Potential remedies for high DFT
1. ICD reprogramming 2.   Device revision
1. ICD reprogramming
- Higher initial energy
- Different shock vector
- “Tuned” 
waveform 
Gold MR et al. J CardiovascElectrophysiol2013
Flatley EE…Moss JD et al. In preparation 2016 Flatley EE…Moss JD et al. In preparation 2016
222222999999 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss 333333000000 MMVeaannntaariggceeummlaeer nnAttr roohffy VVtheemnnttiarriiscc uuallaaftrre AAr rrLrrVhhyyAttDhhmmiiaass iinn PPaattiieennttss wwiitthh VVAADDss
Potential remedies for high DFT Potential remedies for high DFT
1. ICD reprogramming 2.   Device revision3.   LVAD optimization 1. ICD reprogramming 2.   Device revision3.   LVAD optimization
8000 RPM 12000 RPM
J Am CollCardiolHF 2016; 4(3): 208-17 Flatley EE…Moss JD et al. In preparation 2016
33333331111111 MMMVeaaannnntaaarigggceeeummmlaeeer nnnAtttr rooohfffy VVVtheeemnnntttiarrriiisccc uuualllaaaftrrre AAAr rrrLrrrVhhhyyyAtttDhhhmmmiiiaaasss iiinnn PPPaaatttiiieeennntttsss wwwiiittthhh VVVAAADDDsss 33333332222222 MMMVeaaannnntaaarigggceeeummmlaeeer nnnAtttr rooohfffy VVVtheeemnnntttiarrriiisccc uuualllaaaftrrre AAAr rrrLrrrVhhhyyyAtttDhhhmmmiiiaaasss iiinnn PPPaaatttiiieeennntttsss wwwiiittthhh VVVAAADDDsss
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Do ICDs reduce mortality? Needs further study… Do ICDs reduce mortality? Needs further study…
1.0 85 patients, 1996‐2003  • 94 patients
ICD - 77 with ICD
0.8 No ICD - 17 without
P = 
al 0.6 0.01 • 22 with late (>30 days) VA
viv 478 patients, 1991‐2008
ur 0.4 ICD • No significant difference 
S No ICD
in mortality 
0.2 P = 0.024
0.0
0    100    200    300    400    500    600    700    800    900    1000    1100    
Days
RefaatM et al. J Cardiac Fail2012
Cantillon DJ et al. HeartRhythm2010 GaranAR…Uriel Net al. JACC 2013; 61: 2542-50
33333333333333 MMMVeaaannnntaaarigggceeeummmlaeeer nnnAtttr rooohfffy VVVtheeemnnntttiarrriiisccc uuualllaaaftrrre AAAr rrrLrrrVhhhyyyAtttDhhhmmmiiiaaasss iiinnn PPPaaatttiiieeennntttsss wwwiiittthhh VVVAAADDDsss 33333334444444 MMMVeaaannnntaaarigggceeeummmlaeeer nnnAtttr rooohfffy VVVtheeemnnntttiarrriiisccc uuualllaaaftrrre AAAr rrrLrrrVhhhyyyAtttDhhhmmmiiiaaasss iiinnn PPPaaatttiiieeennntttsss wwwiiittthhh VVVAAADDDsss
Do ICDs reduce mortality? Needs further study…
Absence of pre‐op VA 
conferred low risk of 
post‐op VA 
(4.0% vs. 45.5%,
p < 0.001) 
GaranAR…Uriel Net al. JACC 2013; 61: 2542-50 CircArrhythmElectrophysiol2014; 7: 337-46 and 347-51
33333335555555 MMMVeaaannnntaaarigggceeeummmlaeeer nnnAtttr rooohfffy VVVtheeemnnntttiarrriiisccc uuualllaaaftrrre AAAr rrrLrrrVhhhyyyAtttDhhhmmmiiiaaasss iiinnn PPPaaatttiiieeennntttsss wwwiiittthhh VVVAAADDDsss 3333333366666666 MMMMVeaaaannnnntaaaariggggceeeeummmmlaeeeer nnnnAttttr roooohffffy VVVVtheeeemnnnnttttiarrrriiiiscccc uuuuallllaaaaftrrrre AAAAr rrrrLrrrrVhhhhyyyyAttttDhhhhmmmmiiiiaaaassss iiiinnnn PPPPaaaattttiiiieeeennnnttttssss wwwwiiiitttthhhh VVVVAAAADDDDssss
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University of Chicago practice Questions to address:
Clinical Research •What are the clinical implications and predictors of ventricular
arrhythmias after continuous flow LVAD implant?
1. Pre-and post-operative 1. DFT registry
device interrogation • Pre-and post-op CXR •What happens to the ICD after LVAD implant –does the patient
really need it?
2. Elective DFT testing at time • Device interrogation
of first post-op ramp study •How safe and efficacious is mapping and ablation of VT after
(~30-90 days post-implant) 2. Animal studies on shock LVAD implant?
energy distribution with
3. Device reprogramming LVAD being planned •What measures can be taken before or during LVAD implant to
and/or revision on an prevent ventricular arrhythmias?
individual patient basis
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Therapeutic options for late ventricular arrhythmias Therapeutic options for late ventricular arrhythmias
•Medical therapy •Medical therapy
•Sympathetic denervation
Sympathetic
ganglia
Sympathetic
trunk
Clemente Anatomy, 4thed. 1997
Bourke T et al. Circulation2010; 121: 2255-2262
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