Multidisciplinary Approach to Hemodynamic Management During High-Risk Ventricular Tachycardia Ablation

Abstract

Percutaneous ventricular assist devices have been used for high-risk ventricular tachycardia ablation when hemodynamic decompensation is expected. Utilizing a case example, we present our experience with development of a coordinated, team-based approach focused on periprocedural management of patients with high-risk ventricular tachycardia. (Level of Difficulty: Advanced.).

Keywords: AHD, acute hemodynamic decompensation; CPO, cardiac power output; HR-VTA, high-risk ventricular tachycardia ablation; ICD, implantable cardioverter-defibrillator; LV, left ventricular; MCS, mechanical circulatory support; SVO2, mixed venous oxygen saturation; VT, ventricular tachycardia; VTA, ventricular tachycardia ablation; ablation; hemodynamics; multidisciplinary care; pVAD, percutaneous ventricular assist device; percutaneous mechanical circulatory support; ventricular tachycardia.

Graphical abstract

Figure 1

Left Ventricular Mapping: Clinical Ventricular Tachycardia (A) Left ventricular activation map of the clinical ventricular tachycardia. (B) Left ventricular voltage map showing large anterior scar extending to the septum along with ablation lesions. (C) Left bundle morphology, superior axis, precordial transition in V₅, and positive in lead I.

Figure 2

Left Ventricular Mapping: Nonclinical Ventricular Tachycardia (A) Two views of a left ventricular activation map of induced nonclinical ventricular tachycardia showing focal breakthrough from the anterior wall. (B) Right bundle, inferior axis, negative in lead I and negative in V₂ to V₆.

Figure 3

Objective Assessment of Tissue Perfusion Maintenance of end-organ perfusion even during induction of ventricular tachycardia is paramount. We aim to maintain cardiac index >2 L/min/m², mixed venous oxygenation >60%, cardiac power output >0.6 W, and lactate <2 mmol/L, as well as blood pressure and cerebral oximetry 60% to 90% and within 20% of baseline.

Figure 4

Weaning MCS Prolonged tachycardia and hypotension may provoke myocardial ischemia and stunning, increasing reliance on mechanical circulatory support (MCS). We recommend assessment of cardiac power output (CPO), pulsatility of the arterial waveform, mixed venous oxygenation saturation (SVO₂), and lactate before decreasing device flows. We suggest reassessing weaning criteria after each reduction and before withdrawing MCS.

Figure 5

Loss of Intrinsic Arterial Pulsatility Hemodynamics from the percutaneous ventricular assist device console showing loss of pulsatility of native heart and dependence on mechanical circulatory support.