Exploring suitability to electrical storm ablation in patients in waiting list for heart transplantation: A single
Lorenzo Gigli1, Alberto Preda1, Marisa Varrenti1
1Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy.
Insights
Catheter ablation (CA) effectively reduces ventricular arrhythmias in heart transplant candidates experiencing electrical storms. This study establishes CA suitability criteria, showing improved outcomes and reduced hospital stays for selected patients awaiting heart transplantation.
Area of Science:
- Cardiology
- Electrophysiology
- Transplantation Medicine
Background:
- Electrical storm (ES) poses a significant risk for patients awaiting heart transplantation (HT).
- Catheter ablation (CA) is effective in reducing arrhythmic burden but selection criteria for HT candidates with ES are undefined.
- Existing treatments for ES, including antiarrhythmic drugs and stellate ganglion blockade, have limitations.
Purpose of the Study:
- To define selection criteria for catheter ablation (CA) suitability in patients with electrical storm (ES) awaiting heart transplantation (HT).
- To evaluate the efficacy and safety of CA as a bridge therapy to HT in this specific patient population.
- To compare clinical outcomes between patients undergoing CA and those receiving conservative management.
Main Methods:
- Retrospective analysis of 36 patients with ES awaiting HT, resistant to medical therapy.
- Development and application of specific criteria to assess CA suitability, considering cardiomyopathy etiology, hemodynamic status, and procedural feasibility.
- Integration of PAINESD score with clinical and hemodynamic parameters for pre-emptive mechanical circulatory support decisions.
Main Results:
- Acute procedural success for CA was 85% with minimal major complications.
- CA-suitable patients had significantly shorter in-hospital stays (56 vs. 131 days, p=0.004).
- At follow-up, CA patients showed reduced ventricular arrhythmia recurrence (p=0.051) and underwent HT with lower urgency.
Conclusions:
- Specific criteria can identify heart transplant candidates with electrical storm suitable for catheter ablation.
- Catheter ablation serves as a potentially effective bridge therapy, improving outcomes and reducing hospital stay.
- Further research is warranted to confirm CA's role in managing electrical storm in the HT waiting list population.
Abstract:
Electrical storm (ES) is among the most fearsome events in patients in waiting list for heart transplantation (HT) and catheter ablation (CA) demonstrated to be effective in reduce the arrhythmic burden. However, selection criteria for CA suitability in this specific population have never been addressed before. We retrospectively enrolled 36 patients (mean age 51 ± 8 years; 83% men) waiting HT referred to our department for ES resistant to antiarrhythmic drugs and percutaneous stellate ganglion blockade. Twenty patients were judged suitable for VT ablation according to specific criteria including absence of increased arrhythmic burden secondary to volume overload and hemodynamic decompensation; expected CA outcome favorable due to etiology of the cardiomyopathy, no need for coronary revascularization and technical feasibility of the procedure. The pre-emptive use of mechanical circulatory supports (MCS) were discussed integrating the PAINESD score with additional clinical and hemodynamic parameters. Acute procedural success was accounted in 85% of cases with only two major complications. The CA group reported lower length of in-hospital stay after CA suitability evaluation (56 ± 17 vs. 131 ± 64 days, p = .004). Furthermore, at a mean follow-up of 703 ± 145 days, this group showed reduction of ventricular arrhythmia (VA) recurrence leading to implantable cardioverter defibrillator shock (4 vs. 8, p = .051) and underwent HT with a lower level of urgency (0 vs. 6 patients needed for UNOS1 status upgrade). Respectively, one patient of the CA group and two patients of the conservative group died (p = .839). At the end of follow-up, eight patients underwent heart transplantation (p = .964) while four patients underwent Left Ventricular Assist device (LVAD) implantation (p = .440). This pilot study should be a proof for further studies exploring CA of VAs as a possible bridge therapy to HT.
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