Cardiac Rhythm Management
Articles Articles 2011 November

Necessity is the Mother of Invention

DOI: 10.19102/icrm.2011.021106

Brian Olshansky, MD, FHRS, FACC, FAHA

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The excitement of electrophysiology is related to the fact that innovations occur almost routinely. Cardiac electrophysiologists expect something new and different. These expectations tend to occur at a rate much greater than other disciplines in medicine. Living on the “cutting edge” is not a double-edged sword for most electrophysiologists as we welcome, even usher in, challenges that can occur on a day-to-day basis.

Not only do electrophysiologists adapt rapidly to new technology but they create new approaches as are required for the clinical demands that are often continuously changing. The reason for innovative advancements in clinical cardiac electrophysiology center around the type of patients we have, the type of individuals who enter into the profession, the challenges of the medical conditions we treat, and the need to establish newer and better therapies in an environment in which nothing stands still.

In this regard, Dr. Hottigoudar and colleagues address a new challenge: ablation of ventricular tachycardia in patients who have left ventricular assist devices (LVADs). While LVADs have the potential to be “destination therapy” and can improve hemodynamic status markedly, patients who are recipients of LVADs are at risk for developing life-threatening ventricular tachycardias. When and if this occurs, ventricular tachycardia can affect right ventricular function and subsequently affect left ventricular filling.

While some reports have already documented the feasibility of ventricular tachycardia ablation in LVAD patients, good data on mapping and ablation of ventricular tachycardia episodes occurring in these patients are vanishingly small. The authors detail their experience in attempting to find a way to effectively manage this novel, yet important, situation. Not unexpectedly, creative groups, like this one, take the challenge of developing new treatments and inventing such approaches based on their necessity.

Dr. Hottigoudar and colleagues detail their approach to ablation of ventricular tachycardias in LVAD patients. The approach to mapping uses old tools and pacing approaches based on standard ablation and mapping techniques to affect cure, cognizant of the risks of navigating catheters around LVAD cannulae.

While other reports have considered ventricular tachycardia ablation in LVAD patients, the number of reports has been relatively scant. This is the first case series describing de novo ventricular tachycardia in patients who had continuous flow LVADs for a year. As mentioned by the authors, there are specific challenges of performing ventricular tachycardia ablation in patients who have LVADs. Nevertheless, as the necessity arises, once again, electrophysiologists find ways to improve patient outcome by being cognizant of the risks and being knowledgeable about the benefits and how to get there.

It is likely we will be hearing more about ablation of tachycardism patients who have LVADs as the number of patients with such devices continues to rise. The approach taken and the considerations made to undertake a circumspect view of the procedure allows for safe and effective outcomes by creative electrophysiologists who think on their feet and meet the daily needs of the patients as the demand arises. New challenges face all electrophysiologists on a regular basis. We welcome these challenges. I expect our profession will continue to unravel the complexities of arrhythmia management as we all ascribe to the idea that necessity is the mother of invention.

Brian Olshansky, MD, FHRS, FACC, FAHA
Professor of Medicine
Cardiac Electrophysiology
University of Iowa Hospitals
Iowa City, Iowa