Management of arrhythmias in left ventricular assist device recipients

Left ventricular assist device (LVAD) implantation is an important surgical option for patients with advanced heart failure (HF) who are not eligible for heart transplantation (destination therapy) or who are not expected to survive to transplant without durable mechanical circulatory support (bridge-to-transplant). Despite the hemodynamic support provided by LVAD, both atrial and ventricular arrhythmias (AAs and VAs, respectively) are prevalent and contribute to morbidity and mortality, primarily due to right ventricular failure and arrhythmic storm. Management strategies are extrapolated from recommendations for patients with HF with reduced ejection fraction, since available data are limited. Controlling heart rate is a crucial therapeutic approach for AAs since restoration of sinus rhythm often has a minimum effect on hemodynamics. Management of VAs is further complicated by factors unique to LVAD patients, such as suction events. Antiarrhythmic drugs may not work for both AAs and VAs, necessitating escalation therapy or catheter ablation. Given the technical challenges of catheter ablation, a strict cooperation between HF specialists and electrophysiologists is warranted. This review aims to summarize the current scientific evidence and provide clinical guidance for managing arrhythmias in this complex patient group, characterized by significant knowledge gaps.