Catheter Ablation in Patients with Cardiogenic Shock and Refractory Ventricular Tachycardia.

Background ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to antiarrhythmic drugs on mechanical support. Methods - Patients undergoing VT ablation at our center were enrolled in a prospectively maintained registry and screened for the current study (2010-2017). Results All 21 consecutive patients with cardiogenic shock and concomitant refractory ventricular arrhythmia undergoing "bailout" ablation due to inability to wean off mechanical support were included. Median age was 61 years, 86% were males, median LVEF was 20%, 81% had ischemic cardiomyopathy, and PAINESD score was 18 +/- 5. The type of mechanical support in place prior to the procedure was intra-aortic balloon pump (IABP) in 14 patients (67%), Impella CP in 2, ECMO in 2, ECMO and IABP in 2, and ECMO and Impella CP in 1. Endocardial voltage maps showed myocardial scar in 19 patients (90%). The clinical VTs were inducible in 13 patients (62%), whereas 6 patients had PVC induced VF/VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 with inducible clinical VTs. Substrate modification was performed in 15 patients with scar (79%). After ablation and scar modification, the arrhythmia was non-inducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully, but 6 (29%) died during the index admission from persistent cardiogenic shock. Patients who had ventricular arrhythmia and cardiogenic shock on presentation had a trend towards lower in-hospital mortality compared to those who presented with cardiogenic shock and later developed ventricular arrhythmia. Conclusions - "Bailout" ablation for refractory ventricular arrhythmia in cardiogenic shock allowed successful weaning from mechanical support in a large proportion of patients. Mortality remains high, but the majority of patients were discharged home and survived beyond 1 year.