Letter from the Editor in Chief

DOI: 10.19102/icrm.2015.060701

MOUSSA MANSOUR, MD, FHRS, FACC

Editor-in-Chief

Dear Reader,

Performing catheter ablation on patients with hemodynamic compromise is not common in the electrophysiology laboratory. However, the use of assist devices to provide hemodynamic support during ablation has been slowly increasing over the past few years, and several recent reports have described the use of mechanical circulatory support to facilitate the ablation of unstable arrhythmias. This concept is highlighted in the article by Dr. Gentlesk and colleagues in this issue of the Journal. They described the case of a patient with incessant orthodromic atrioventricular reentry tachycardia secondary to a left-sided accessory pathway that was refractory to pharmacological therapy. The tachycardia resulted in severe cardiomyopathy and cardiogemic shock. The patient was placed on ECMO which allowed the successful ablation of the accessory pathway and the subsequent recovery of the ejection fraction.

The need for mechanical circulatory support is very rare during SVT ablation. The importance of this case however is highlighting the value of assist devices during catheter ablation in unstable hemodynamic situations in general. The more common clinical scenario would be during ablation of unstable ventricular tachycardia. The most commonly used device in this setting is intra-aortic balloon pump (IABP). While easy to use, IABP has limited ability to provide significant hemodynamic support especially during elevated heart rates. The use of ECMO and other left ventricular assist devices such as the Impella device has been gaining momentum. Over the past few years a handful of reports have demonstrated the efficacy of these devices in facilitating ablation of unstable ventricular tachycardia in the setting of structural heart disease.

The use of ECMO and left ventricular assist devices can be challenging. The patients are often sick and have severe comorbidities including congestive heart failure and peripheral vascular disease. Moreover the deployment of these devices requires a high level of skill and expertise not only for the insertion but also for the management of the device to ensure proper function and interpretation of the data. As a result, it is best to approach these situations in a multidisciplinary fashion. A patient-centered approach consisting of a team that includes an elecgtrophysiologist, a congestive heart failure specialist, an interventional cardiologist, and a cardiac surgeon would provide the best chance of success in these complex situations. This model is currently being used in major medical centers.

Increasingly we find ourselves treating patients with complex medical conditions. This trend is due in part to the aging population as well as advances in medicine which are both allowing patients to survive conditions that were considered untreatable previously. A multidisciplinary approach is critical for the successful treatment of these patients.

Best regards and I hope you enjoy reading this issue of the Journal.

Editor-in-Chief

Moussa Mansour, MD, FHRS, FACC
Editor-in-Chief
The Journal of Innovations in Cardiac Rhythm Management
MMansour@InnovationsInCRM.com
Director, Cardiac Electrophysiology Laboratory
Director, Atrial Fibrillation Program
Massachusetts General Hospital
Boston, MA